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Zemke AC, Hilliam Y, Stapleton AL, Kimple AJ, Goralski JL, Shaffer AD, Pilewski JM, Senior BA, Lee SE, Cooper VS. Elexacaftor-tezacaftor-ivacaftor decreases pseudomonas abundance in the sinonasal microbiome in cystic fibrosis. Int Forum Allergy Rhinol 2024; 14:928-938. [PMID: 37837613 DOI: 10.1002/alr.23288] [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: 07/13/2023] [Revised: 09/15/2023] [Accepted: 09/23/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) is common in individuals with cystic fibrosis (CF) and is marked by chronic inflammation and episodes of infection that negatively impact quality of life. Several studies have shown that elexacaftor-tezacaftor-ivacaftor (ETI) improves symptoms and examination findings in CF-CRS. The current study determines the effect of ETI on the sinonasal microbiota in CF. METHODS Sinonasal samples were collected under endoscopic visualization before and after starting ETI. Samples were subjected to 16S amplicon sequencing and sequences were processed with the QIIME2 pipeline with subsequent analysis using the vegan R-package. RESULTS Twenty-nine individual baseline samples and 23 sample pairs pre-/post-ETI were available. At baseline, the cohort had samples dominated by Staphylococcus, and alpha diversity was lower than that of a published reference set of individuals without sinonasal disease. Individuals with prior sinus surgery had lower alpha diversity as measured by Shannon Index, Observed Richness, and Faith's phylogenetic diversity Index. Beta diversity differed between individuals with and without allergic rhinitis, with higher Staphylococcus abundance in those with allergic rhinitis. No change in alpha or beta diversity was seen after a median of 9 months on ETI. With ETI, the Pseudomonas genus and the genus containing Burkholderia decreased in samples containing these taxa at baseline. Pseudomonas abundance decreased with treatment as measured by qPCR. Core sinonasal microbiome members Staphylococcus, Corynebacterium, and Streptococcus were unchanged, while Moraxella increased with ETI. CONCLUSIONS Treatment with ETI leads to a reduction in Pseudomonas abundance within the sinonasal microbiome of individuals with Pseudomonas at baseline.
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Affiliation(s)
- Anna C Zemke
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yasmin Hilliam
- Department of Microbiology & Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Amanda L Stapleton
- Department of Otolaryngology-Head & Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam J Kimple
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jennifer L Goralski
- Division of Pulmonary Diseases & CCM, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Amber D Shaffer
- Department of Otolaryngology-Head & Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brent A Senior
- Department of Otolaryngology-Head & Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stella E Lee
- Department of Otolaryngology-Head & Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Vaughn S Cooper
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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2
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Beswick DM, Liu CM, Overdevest JB, Zemke A, Khatiwada A, Gudis DA, Miller JE, Kimple A, Tervo JP, DiMango E, Goralski JL, Keating C, Senior B, Stapleton AL, Eshaghian PH, Mace JC, Markarian K, Alt JA, Bodner TE, Chowdhury NI, Getz AE, Hwang PH, Khanwalker A, Lee JT, Li DA, Norris M, Nayak JV, Owens C, Patel ZM, Poch K, Schlosser RJ, Smith KA, Smith TL, Soler ZM, Suh JD, Turner GA, Wang MB, Saavedra MT, Taylor Cousar JL. Predictors of Sinonasal Improvement After Highly Effective Modulator Therapy in Adults with Cystic Fibrosis. Laryngoscope 2024. [PMID: 38634358 DOI: 10.1002/lary.31438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/04/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES The 22-question SinoNasal Outcome Test (SNOT-22) assesses chronic rhinosinusitis (CRS) severity. We aimed to identify predictors of SNOT-22 score improvement following highly effective modulator therapy (HEMT) initiation and to corroborate the SNOT-22 minimal clinically important difference (MCID) in adults with cystic fibrosis (CF). METHODS Prospective observational data was pooled from four studies across 10 US centers investigating people with CF (PwCF) and CRS. Three studies evaluated HEMT's impact on CRS. For participants enrolled prior to HEMT initiation, SNOT-22 scores were obtained at baseline and after 3-6 months of HEMT. Multivariate regression identified predictors of improvement. Cronbach's alpha and four distribution-based methods were used to assess internal consistency and calculate the MCID of the SNOT-22. RESULTS A total of 184 PwCF participated with mean baseline SNOT-22 scores ranging from 18.1 to 56.7. Cronbach's alpha was ≥0.90 across sites. Participants at sites with pre- and post-HEMT data reported improvement in SNOT-22 scores after initiating HEMT (all p < 0.05). Worse baseline SNOT-22 score (odds ratio (OR): 1.05, p < 0.001, 95% CI: 1.02-1.08), F508del homozygosity (OR: 4.30, p = 0.040, 95% CI: 1.14-18.99), and absence of prior modulator therapy (OR: 4.99, p = 0.017, 95% CI: 1.39-20.11) were associated with greater SNOT-22 improvement. The mean MCID calculated via distribution-based methods was 8.5. CONCLUSION Worse baseline sinonasal symptoms, F508del homozygosity, and absence of prior modulator therapy predicted greater improvement after HEMT initiation. The mean MCID for SNOT-22 in PwCF is 8.5 points, similar to non-CF individuals with CRS, and provides a threshold specifically for PwCF. The SNOT-22 has strong internal consistency in PwCF. LEVEL OF EVIDENCE 3 Laryngoscope, 2024.
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Affiliation(s)
- Daniel M Beswick
- Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles, California, U.S.A
| | - Christine M Liu
- Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles, California, U.S.A
| | - Jonathan B Overdevest
- Department of Otolaryngology-Head and Neck Surgery, Columbia University, New York, New York, U.S.A
| | - Anna Zemke
- Division of Pulmonary Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Aastha Khatiwada
- Department of Biostatistics, National Jewish Health, Denver, Colorado, U.S.A
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University, New York, New York, U.S.A
| | - Jessa E Miller
- Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles, California, U.S.A
| | - Adam Kimple
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - Jeremy P Tervo
- Department of Otolaryngology-Head and Neck Surgery, Columbia University, New York, New York, U.S.A
| | - Emily DiMango
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, New York, U.S.A
| | - Jennifer L Goralski
- Department of Pulmonary Medicine, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - Claire Keating
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University, New York, New York, U.S.A
| | - Brent Senior
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - Amanda L Stapleton
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Patricia H Eshaghian
- Department of Pulmonary Medicine, University of California, Los Angeles, California, U.S.A
| | - Jess C Mace
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Karolin Markarian
- CTSI, David Geffen School of Medicine, University of California, Los Angeles, California, U.S.A
| | - Jeremiah A Alt
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Todd E Bodner
- Department of Psychology, Portland State University, Portland, Oregon, U.S.A
| | - Naweed I Chowdhury
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt Health, Nashville, Tennessee, U.S.A
| | - Anne E Getz
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado, Aurora, Colorado, U.S.A
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, U.S.A
| | - Ashoke Khanwalker
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado, Aurora, Colorado, U.S.A
| | - Jivianne T Lee
- Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles, California, U.S.A
| | - Douglas A Li
- Department of Pulmonary Medicine, University of California, Los Angeles, California, U.S.A
| | - Meghan Norris
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - Jayakar V Nayak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, U.S.A
| | - Cameran Owens
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado, Aurora, Colorado, U.S.A
| | - Zara M Patel
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, U.S.A
| | - Katie Poch
- Department of Medicine, National Jewish Health, Denver, Colorado, U.S.A
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Greenville, South Carolina, U.S.A
| | - Kristine A Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Timothy L Smith
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Jeffrey D Suh
- Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles, California, U.S.A
| | - Grant A Turner
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Marilene B Wang
- Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles, California, U.S.A
| | - Milene T Saavedra
- Department of Medicine, National Jewish Health, Denver, Colorado, U.S.A
| | - Jennifer L Taylor Cousar
- Department of Medicine, National Jewish Health, Denver, Colorado, U.S.A
- Department of Pediatrics, National Jewish Health, Denver, Colorado, U.S.A
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3
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Peng G, Taylor-Cousar JL, Lee M, Keller A, West NE, Kazmerski TM, Goralski JL, Aitken ML, Roe AH, Hadjiliadis D, Uluer A, Flume PA, Mody S, Bray LA, Jain R. Association between unplanned pregnancies and maternal exacerbations in cystic fibrosis. J Cyst Fibros 2023; 22:796-803. [PMID: 37029015 DOI: 10.1016/j.jcf.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION Following availability of the highly effective cystic fibrosis (CF) transmembrane conductance regulator modulator, elexacaftor/tezacaftor/ivacaftor, there was a near doubling of pregnancies reported in the United States (US) in people with CF. We sought to determine health impacts of planned (PP) versus unplanned pregnancies (UP). METHODS We collected retrospective pregnancy data from January 2010-December 2020 from 11 US CF centers. After adjusting for potential confounding effects, we conducted multivariable, multilevel longitudinal regression analysis using mixed effect modeling to assess whether changes in percent predicted forced expiratory volume in one second (ppFEV1), body mass index (BMI), and pulmonary exacerbations (PEx) 1-year-pre- to 1-year-post-pregnancy were associated with pregnancy planning. RESULTS Our analysis included 163 people with 226 pregnancies; the cohort had a mean age at conception of 29.6 years, mean pre-pregnancy ppFEV1 of 75.4 and BMI of 22.5 kg/m2. PpFEV1 declined in both PP (adjusted decline of -2.5 (95% CI: -3.8, -1.2)) and UP (adjusted decline of -3.0 (95% CI: -4.6, -1.4)) groups, they did not differ from each other (p = 0.625). We observed a difference in change in the annual number of PEx pre- to post-pregnancy (PP: 0.8 (0.7, 1.1); UP: 1.3 (1.0, 1.7); interaction effect p = 0.029). In a subset of people with available infant data, infants resulting from UP had more preterm births, lower APGAR scores, and more intensive care unit stays. CONCLUSIONS Following UP, there is an increased trajectory for PEx and potentially for infant complications compared to PP. Clinicians should consider increased surveillance in the setting of UP.
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Affiliation(s)
- Giselle Peng
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States
| | | | - MinJae Lee
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States
| | - Ashley Keller
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States
| | | | | | | | | | - Andrea H Roe
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Denis Hadjiliadis
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Ahmet Uluer
- Harvard/Boston Children's Hospital and Brigham & Women's Hospital, Boston, MA, United States
| | - Patrick A Flume
- Medical University of South Carolina, Charleston, SC, United States
| | - Sheila Mody
- University of California San Diego, San Diego, CA, United States
| | - Leigh Ann Bray
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Raksha Jain
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. -8558, Dallas, TX 75230, United States.
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4
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Goralski JL, Hoppe JE, Mall MA, McColley SA, McKone E, Ramsey B, Rayment JH, Robinson P, Stehling F, Taylor-Cousar JL, Tullis E, Ahluwalia N, Chin A, Chu C, Lu M, Niu T, Weinstock T, Ratjen F, Rosenfeld M. Phase 3 Open-Label Clinical Trial of Elexacaftor/Tezacaftor/Ivacaftor in Children Aged 2-5 Years with Cystic Fibrosis and at Least One F508del Allele. Am J Respir Crit Care Med 2023; 208:59-67. [PMID: 36921081 PMCID: PMC10870849 DOI: 10.1164/rccm.202301-0084oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [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: 01/13/2023] [Accepted: 03/15/2023] [Indexed: 03/17/2023] Open
Abstract
Rationale: Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) has been shown to be safe and effective in people with cystic fibrosis (CF) aged ⩾6 years with at least one F508del-CFTR allele but has not been studied in younger children. Objectives: To evaluate the safety, pharmacokinetics, pharmacodynamics, and efficacy of ELX/TEZ/IVA in children with CF aged 2-5 years. Methods: In this phase 3, open-label, two-part study (parts A and B), children weighing <14 kg (on Day 1) received ELX 80 mg once daily (qd), TEZ 40 mg qd, and IVA 60 mg each morning and 59.5 mg each evening; children weighing ⩾14 kg received ELX 100 mg qd, TEZ 50 mg qd, and IVA 75 mg every 12 hours. Measurements and Main Results: The primary endpoints for part A (15-d treatment period) were pharmacokinetics and safety and tolerability. For part B (24-wk treatment period), the primary endpoint was safety and tolerability; secondary endpoints included pharmacokinetics and absolute changes from baseline in sweat chloride concentration and lung clearance index2.5 (LCI2.5, defined as the number of lung turnovers required to reduce the end tidal N2 concentration to 2.5% of its starting value) through Week 24. Analysis of pharmacokinetic data from 18 children enrolled in part A confirmed the appropriateness of the part B dosing regimen. In part B, 75 children (F508del/minimal function genotypes, n = 52; F508del/F508del genotype, n = 23) were enrolled and dosed. Seventy-four children (98.7%) had adverse events, which were all mild (62.7%) or moderate (36.0%) in severity. The most common adverse events were cough, fever, and rhinorrhea. Decreases in sweat chloride concentration (-57.9 mmol/L; 95% confidence interval [CI], -61.3 to -54.6; n = 69) and LCI2.5 (-0.83 U; 95% CI, -1.01 to -0.66; n = 50) were observed from baseline through Week 24. Mean body mass index was within the normal range at baseline and remained stable at Week 24. Conclusions: In this open-label study in children 2-5 years of age, ELX/TEZ/IVA treatment was generally safe and well tolerated, with a safety profile consistent with that observed in older age groups, and led to clinically meaningful reductions in sweat chloride concentration and LCI2.5. Clinical trial registered with www.clinicaltrials.gov (NCT04537793).
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Affiliation(s)
| | - Jordana E. Hoppe
- University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Marcus A. Mall
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Center for Lung Research, Associated Partner, Berlin, Germany
| | - Susanna A. McColley
- Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Bonnie Ramsey
- Seattle Children’s Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Jonathan H. Rayment
- University of British Columbia and British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Phil Robinson
- The Royal Children’s Hospital, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Florian Stehling
- Children’s Hospital, University of Duisburg-Essen, Essen, Germany
| | | | - Elizabeth Tullis
- St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Anna Chin
- Vertex Pharmaceuticals Inc., Boston, Massachusetts; and
| | - Chenghao Chu
- Vertex Pharmaceuticals Inc., Boston, Massachusetts; and
| | - Mengdi Lu
- Vertex Pharmaceuticals Inc., Boston, Massachusetts; and
| | - Tao Niu
- Vertex Pharmaceuticals Inc., Boston, Massachusetts; and
| | | | | | - Margaret Rosenfeld
- Seattle Children’s Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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5
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Chung SH, Huynh KM, Goralski JL, Chen Y, Yap PT, Ceppe AS, Powell MZ, Donaldson SH, Lee YZ. Feasibility of free-breathing 19 F MRI image acquisition to characterize ventilation defects in CF and healthy volunteers at wash-in. Magn Reson Med 2023; 90:79-89. [PMID: 36912481 PMCID: PMC10149612 DOI: 10.1002/mrm.29630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/27/2023] [Accepted: 02/15/2023] [Indexed: 03/14/2023]
Abstract
PURPOSE To explore the feasibility of measuring ventilation defect percentage (VDP) using 19 F MRI during free-breathing wash-in of fluorinated gas mixture with postacquisition denoising and to compare these results with those obtained through traditional Cartesian breath-hold acquisitions. METHODS Eight adults with cystic fibrosis and 5 healthy volunteers completed a single MR session on a Siemens 3T Prisma. 1 H Ultrashort-TE MRI sequences were used for registration and masking, and ventilation images with 19 F MRI were obtained while the subjects breathed a normoxic mixture of 79% perfluoropropane and 21% oxygen (O2 ). 19 F MRI was performed during breath holds and while free breathing with one overlapping spiral scan at breath hold for VDP value comparison. The 19 F spiral data were denoised using a low-rank matrix recovery approach. RESULTS VDP measured using 19 F VIBE and 19 F spiral images were highly correlated (r = 0.84) at 10 wash-in breaths. Second-breath VDPs were also highly correlated (r = 0.88). Denoising greatly increased SNR (pre-denoising spiral SNR, 2.46 ± 0.21; post-denoising spiral SNR, 33.91 ± 6.12; and breath-hold SNR, 17.52 ± 2.08). CONCLUSION Free-breathing 19 F lung MRI VDP analysis was feasible and highly correlated with breath-hold measurements. Free-breathing methods are expected to increase patient comfort and extend ventilation MRI use to patients who are unable to perform breath holds, including younger subjects and those with more severe lung disease.
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Affiliation(s)
- Sang Hun Chung
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Khoi Minh Huynh
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Goralski
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Marsico Lung Institute/UNC Cystic Fibrosis Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yong Chen
- Department of Radiology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Pew-Thian Yap
- Department of Radiology and Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Agathe S Ceppe
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Marsico Lung Institute/UNC Cystic Fibrosis Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Margret Z Powell
- Marsico Lung Institute/UNC Cystic Fibrosis Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Scott H Donaldson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Marsico Lung Institute/UNC Cystic Fibrosis Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Yueh Z Lee
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Radiology and Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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6
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Fajac I, Daines C, Durieu I, Goralski JL, Heijerman H, Knoop C, Majoor C, Bruinsma BG, Moskowitz S, Prieto-Centurion V, Van Brunt K, Zhang Y, Quittner A. Non-respiratory health-related quality of life in people with cystic fibrosis receiving elexacaftor/tezacaftor/ivacaftor. J Cyst Fibros 2023; 22:119-123. [PMID: 36114142 DOI: 10.1016/j.jcf.2022.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/01/2022] [Accepted: 08/26/2022] [Indexed: 10/14/2022]
Abstract
Elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) was shown to be safe and efficacious in people with cystic fibrosis (CF) heterozygous for F508del and a minimal function mutation (F/MF) or homozygous for F508del (F/F) in two pivotal Phase 3 trials, significantly improving percentage predicted forced expiratory volume in 1 second, Cystic Fibrosis Questionnaire-Revised, Respiratory Domain (CFQ-R RD) scores, and sweat chloride concentration. Here, we analyzed the 11 non-respiratory domains (non-RDs) of the CFQ-R, which assess general health-related quality of life (i.e., Physical Functioning, Role Functioning, Vitality, Health Perceptions, Emotional Functioning, and Social Functioning) and quality of life impacted by CF (i.e., Body Image, Eating Problems, Treatment Burden, Weight, and Digestive Symptoms), for participants in these two Phase 3 trials. ELX/TEZ/IVA treatment led to higher scores in all CFQ-R non-RDs, with improvements in most domains compared with control treatments. These findings demonstrate that ELX/TEZ/IVA improves a range of CF-specific symptoms and general functioning and well-being.
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Affiliation(s)
| | - Cori Daines
- University of Arizona, Banner University Medical Center, Tucson, AZ, US.
| | - Isabelle Durieu
- Hospices Civils de Lyon, Adult Cystic Fibrosis Centre, Université de Lyon, France.
| | - Jennifer L Goralski
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, US.
| | - Harry Heijerman
- University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Christiane Knoop
- Department of Chest Medicine, Hôpital Erasme, Brussels, Belgium.
| | - Christof Majoor
- Department of Respiratory Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | | | | | | | | | - Yaohua Zhang
- Vertex Pharmaceuticals Incorporated, Boston, MA, USA.
| | - Alexandra Quittner
- Behavioral Health Systems Research, 2460 Tigertail Avenue, Miami, FL 33139, US.
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7
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Goralski JL, Chung SH, Ceppe AS, Powell MZ, Sakthivel M, Handly BD, Lee YZ, Donaldson SH. Dynamic Perfluorinated Gas MRI Shows Improved Lung Ventilation in People with Cystic Fibrosis after Elexacaftor/Tezacaftor/Ivacaftor: An Observational Study. J Clin Med 2022; 11:jcm11206160. [PMID: 36294480 PMCID: PMC9604637 DOI: 10.3390/jcm11206160] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 01/27/2023] Open
Abstract
The availability of highly effective CFTR modulators is revolutionizing the treatment of cystic fibrosis (CF) and drastically improving outcomes. MRI-based imaging modalities are now emerging as highly sensitive endpoints, particularly in the setting of mild lung disease. Adult CF patients were recruited from a single center prior to starting treatment with E/T/I. The following studies were obtained before and after one month on treatment: spirometry, multiple breath nitrogen washout (MBW), 1H UTE MRI (structural images) and 19F MRI (ventilation images). Changes between visits were calculated, as were correlations between FEV1, lung clearance index (LCI), MRI structural scores, and MRI-based ventilation descriptors. Eight subjects had complete datasets for evaluation. Consistent with prior clinical trials, FEV1 and LCI improved after 28 days of E/T/I use. 1H UTE MRI detected improvements in bronchiectasis/airway wall thickening score and mucus plugging score after 28 days of therapy. 19F MRI demonstrated improvements in fractional lung volume with slow gas washout time (FLV↑tau2) and ventilation defect percentage (VDP). Improvements in FLV↑tau2 and VDP correlated with improvement in FEV1 (r = 0.81 and 0.86, respectively, p < 0.05). This observational study establishes the ability of 19F MRI and 1H UTE MRI to detect improvements in lung structure and function after E/T/I treatment. This study supports further development of 19F MRI and 1H UTE MRI as outcome measures for cystic fibrosis research and drug development.
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Affiliation(s)
- Jennifer L. Goralski
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Marsico Lung Institute/UNC Cystic Fibrosis Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Correspondence:
| | - Sang Hun Chung
- Department of Biomedical Engineering, University of North Carolina at Chapel Hill—North Carolina State University, Chapel Hill, NC 27599, USA
| | - Agathe S. Ceppe
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Marsico Lung Institute/UNC Cystic Fibrosis Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Margret Z. Powell
- Marsico Lung Institute/UNC Cystic Fibrosis Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Muthu Sakthivel
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Brian D. Handly
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Yueh Z. Lee
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Scott H. Donaldson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
- Marsico Lung Institute/UNC Cystic Fibrosis Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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8
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Stapleton AL, Kimple AJ, Goralski JL, Nouraie SM, Branstetter BF, Shaffer AD, Pilewski JM, Senior BA, Lee SE, Zemke AC. Elexacaftor-Tezacaftor- Ivacaftor improves sinonasal outcomes in cystic fibrosis. J Cyst Fibros 2022; 21:792-799. [PMID: 35300931 PMCID: PMC9470769 DOI: 10.1016/j.jcf.2022.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Many individuals with cystic fibrosis (CF) have chronic rhinosinusitis resulting in nasal obstruction, sinus infections, and repeated surgeries. Elexacaftor-tezacaftor-ivacaftor is a highly effective modulator therapy approved for individuals aged 6 years or older with CF who have at least one F508del allele or other responsive mutation. The current study tests the hypothesis that ELX/TEZ/IVA improves sinonasal disease in CF. METHODS The study was a pre/post, observational cohort study conducted at two sites. Participants underwent a study visit prior to starting ELX/TEZ/IVA and a second visit at a median of 9 months on therapy. Each visit included sinus CT scan, rigid nasal endoscopy, and sweat chloride measurement. Symptoms were measured with the 22 item Sinonasal Outcome Test at scheduled intervals during the study. Regression models were used to test for improvement in symptoms, endoscopy, and CT scales. RESULTS The study enrolled 34 individuals, with a median age of 27 years (range 12-60). Symptoms improved within 7 days of therapy and plateaued by day 28. Endoscopic crusting resolved and nasal polyposis improved, with a decrease in size or resolution of polyps. Sinus opacification and mucosal thickening improved on CT radiographs with treatment. CONCLUSIONS Sinonasal symptoms improved rapidly and durably for at least 180 days on ELX/TEZ/IVA therapy. Objective measures of disease including endoscopic and CT findings improved with ELX/TEZ/IVA.
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Affiliation(s)
- Amanda L Stapleton
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh, United States
| | - Adam J Kimple
- Department of Otolaryngology - Head & Neck Surgery, University of North Carolina, United States
| | - Jennifer L Goralski
- Division of Pulmonary Diseases & Critical Care Medicine, University of North Carolina, United States
| | - S Mehdi Nouraie
- Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, University of Pittsburgh, United States
| | - Barton F Branstetter
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh, United States; Department of Radiology, University of Pittsburgh, United States; Department of Biomedical Informatics, University of Pittsburgh, United States
| | - Amber D Shaffer
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh, United States
| | - Joseph M Pilewski
- Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, University of Pittsburgh, United States
| | - Brent A Senior
- Department of Otolaryngology - Head & Neck Surgery, University of North Carolina, United States
| | - Stella E Lee
- Department of Otolaryngology - Head and Neck Surgery, University of Pittsburgh, United States
| | - Anna C Zemke
- Department of Medicine, Division of Pulmonary, Allergy & Critical Care Medicine, University of Pittsburgh, United States
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9
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Raraigh KS, Paul KC, Goralski JL, Worthington EN, Faino AV, Sciortino S, Wang Y, Aksit MA, Ling H, Osorio DL, Onchiri FM, Patel SU, Merlo CA, Montemayor K, Gibson RL, West NE, Thakerar A, Bridges RJ, Sheppard DN, Sharma N, Cutting GR. CFTR bearing variant p.Phe312del exhibits function inconsistent with phenotype and negligible response to ivacaftor. JCI Insight 2022; 7:148841. [PMID: 35315358 PMCID: PMC8986068 DOI: 10.1172/jci.insight.148841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
The chloride channel dysfunction caused by deleterious cystic fibrosis transmembrane conductance regulator (CFTR) variants generally correlates with severity of cystic fibrosis (CF). However, 3 adults bearing the common severe variant p.Phe508del (legacy: F508del) and a deletion variant in an ivacaftor binding region of CFTR (p.Phe312del; legacy: F312del) manifested only elevated sweat chloride concentration (sw[Cl-]; 87-105 mEq/L). A database review of 25 individuals with F312del and a CF-causing variant revealed elevated sw[Cl-] (75-123 mEq/L) and variable CF features. F312del occurs at a higher-than-expected frequency in the general population, confirming that individuals with F312del and a CF-causing variant do not consistently develop overt CF features. In primary nasal cells, CFTR bearing F312del and F508del generated substantial chloride transport (66.0% ± 4.5% of WT-CFTR) but did not respond to ivacaftor. Single-channel analysis demonstrated that F312del did not affect current flow through CFTR, minimally altered gating, and ablated the ivacaftor response. When expressed stably in CF bronchial epithelial (CFBE41o-) cells, F312del-CFTR demonstrated residual function (50.9% ± 3.3% WT-CFTR) and a subtle decrease in forskolin response compared with WT-CFTR. F312del provides an exception to the established correlation between CFTR chloride transport and CF phenotype and informs our molecular understanding of ivacaftor response.
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Affiliation(s)
| | | | - Jennifer L Goralski
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Erin N Worthington
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anna V Faino
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Stanley Sciortino
- California Department of Public Health, Genetic Disease Screening Program, Richmond, California, USA
| | - Yiting Wang
- University of Bristol, Bristol, United Kingdom
| | | | - Hua Ling
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | - Amita Thakerar
- Rosalind Franklin University of Medicine and Science, Center for Genetic Diseases, North Chicago, Illinois, USA
| | - Robert J Bridges
- Rosalind Franklin University of Medicine and Science, Center for Genetic Diseases, North Chicago, Illinois, USA
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10
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Bacon DR, Stapleton A, Goralski JL, Ebert CS, Thorp BD, Nouraie M, Shaffer AD, Senior BA, Lee SE, Zemke AC, Kimple AJ. Olfaction before and after initiation of elexacaftor-tezacaftor-ivacaftor in a cystic fibrosis cohort. Int Forum Allergy Rhinol 2022; 12:223-226. [PMID: 34709729 PMCID: PMC8792160 DOI: 10.1002/alr.22891] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/26/2021] [Accepted: 08/09/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Daniel R. Bacon
- Dept. Otolaryngology – Head & Neck Surgery, Univ. North Carolina
| | | | | | - Charles S. Ebert
- Dept. Otolaryngology – Head & Neck Surgery, Univ. North Carolina
| | - Brian D. Thorp
- Dept. Otolaryngology – Head & Neck Surgery, Univ. North Carolina
| | | | | | - Brent A. Senior
- Dept. Otolaryngology – Head & Neck Surgery, Univ. North Carolina
| | | | | | - Adam J. Kimple
- Dept. Otolaryngology – Head & Neck Surgery, Univ. North Carolina
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11
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Thambuluru SR, Kyazimzade S, Despotes KA, Kirk D, Goralski JL. Acute ST-elevation myocardial infarction in two young women with cystic fibrosis and cystic fibrosis-related diabetes. J Cyst Fibros 2021; 21:e44-e47. [PMID: 34911664 DOI: 10.1016/j.jcf.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
Ischemic heart disease is rarely reported in people with cystic fibrosis (PwCF) despite multiple potential risk factors. Here we report two cases of ST elevation myocardial infarction (STEMI), both in young women with cystic fibrosis (CF) and cystic fibrosis related diabetes (CFRD). These cases illustrate the importance of considering myocardial injury/infarction in the differential diagnosis of patients with CF and chest pain or shortness of breath, and addressing the growing risk of cardiovascular disease (CVD).
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Affiliation(s)
- Sirisha Reddy Thambuluru
- Division of Endocrinology & Metabolism, University of North Carolina, Chapel Hill, NC, United States
| | - Sayyad Kyazimzade
- Department of Internal Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Katherine A Despotes
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, United States; Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, NC, United States
| | - Deepa Kirk
- Division of Endocrinology & Metabolism, University of North Carolina, Chapel Hill, NC, United States
| | - Jennifer L Goralski
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC, United States; Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, NC, United States.
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12
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Goralski JL. Foretelling Early Lung Disease Progression in CF: The Combined Benefits of MRI and Newborn Screen. Am J Respir Crit Care Med 2021; 204:880-881. [PMID: 34384036 PMCID: PMC8534612 DOI: 10.1164/rccm.202107-1727ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Jennifer L Goralski
- University of North Carolina at Chapel Hill, 2331, Medicine, Chapel Hill, North Carolina, United States;
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13
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Todd SH, Sonntag EA, Buchanan ML, Jones BW, Dellon EP, Donaldson SH, Goralski JL. Development of an Advance Care Planning Protocol in a Cystic Fibrosis Outpatient Clinic. J Palliat Med 2021; 24:1383-1386. [PMID: 34191614 DOI: 10.1089/jpm.2021.0186] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Advance care planning (ACP) is recommended for all patients with cystic fibrosis (CF), yet clear implementation guidelines do not exist. Methods: The University of North Carolina Adult CF Care Team developed a process to implement semistructured multidisciplinary outpatient ACP meetings as routine care for patients with CF. Premeeting and post-meeting surveys were used to elicit patients' attitudes toward ACP. Results: Twenty-seven adults with CF completed a face-to-face ACP meeting, and 13 completed both surveys. Following the multidisciplinary ACP meeting, overall scores for understanding of ACP topics improved by 4.5 points (p = 0.003). Conclusion: We successfully implemented sustainable ACP meetings for adults with CF and found increased comfort with ACP and documentation of wishes after ACP meetings. It is important for CF care providers to meet the needs of this patient population by ensuring that ACP is in place before crisis situations.
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Affiliation(s)
- Sarah H Todd
- Departments of Medicine and Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elizabeth A Sonntag
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Marianne L Buchanan
- UNC Hospitals Department of Social Work, and The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brooke W Jones
- UNC Hospitals Department of Social Work, and The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisabeth P Dellon
- Division of Pediatric Pulmonology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Scott H Donaldson
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Goralski
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Pediatric Pulmonology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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14
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Abstract
With an increasing number of patients with cystic fibrosis (CF) receiving highly effective CFTR (cystic fibrosis transmembrane regulator protein) modulator therapy, particularly at a young age, there is an increasing need to identify imaging tools that can detect and regionally visualize mild CF lung disease and subtle changes in disease state. In this review, we discuss the latest developments in imaging modalities for both structural and functional imaging of the lung available to CF clinicians and researchers, from the widely available, clinically utilized imaging methods for assessing CF lung disease-chest radiography and computed tomography-to newer techniques poised to become the next phase of clinical tools-structural/functional proton and hyperpolarized gas magnetic resonance imaging (MRI). Finally, we provide a brief discussion of several newer lung imaging techniques that are currently available only in selected research settings, including chest tomosynthesis, and fluorinated gas MRI. We provide an update on the clinical and/or research status of each technique, with a focus on sensitivity, early disease detection, and possibilities for monitoring treatment efficacy.
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Affiliation(s)
- Jennifer L Goralski
- UNC Cystic Fibrosis Center, Marsico Lung Institute, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of Pediatric Pulmonology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Neil J Stewart
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital, Cincinnati, Ohio.,Department of Infection, Immunity & Cardiovascular Disease, POLARIS Group, Imaging Sciences, University of Sheffield, Sheffield, UK
| | - Jason C Woods
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio.,Department of Radiology, Cincinnati Children's Hospital, Cincinnati, Ohio
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15
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McCallister A, Chung SH, Antonacci M, Z Powell M, Ceppe AS, Donaldson SH, Lee YZ, Branca RT, Goralski JL. Comparison of single breath hyperpolarized 129 Xe MRI with dynamic 19 F MRI in cystic fibrosis lung disease. Magn Reson Med 2020; 85:1028-1038. [PMID: 32770779 PMCID: PMC7689687 DOI: 10.1002/mrm.28457] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 12/28/2022]
Abstract
Purpose To quantitatively compare dynamic 19F and single breath hyperpolarized 129Xe MRI for the detection of ventilation abnormalities in subjects with mild cystic fibrosis (CF) lung disease. Methods Ten participants with stable CF and a baseline FEV1 > 70% completed a single imaging session where dynamic 19F and single breath 129Xe lung ventilation images were acquired on a 3T MRI scanner. Ventilation defect percentages (VDP) values between 19F early‐breath, 19F maximum‐ventilation, 129Xe low‐resolution, and 129Xe high‐resolution images were compared. Dynamic 19F images were used to determine gas wash‐in/out rates in regions of ventilation congruency and mismatch between 129Xe and 19F. Results VDP values from high‐resolution 129Xe images were greater than from low‐resolution images (P = .001), although these values were significantly correlated (r = 0.68, P = .03). Early‐breath 19F VDP and max‐vent 19F VDP also showed significant correlation (r = 0.75, P = .012), with early‐breath 19F VDP values being significantly greater (P < .001). No correlation in VDP values were detected between either 19F method or high‐res 129Xe images. In addition, the location and volume of ventilation defects were often different when comparing 129Xe and 19F images from the same subject. Areas of ventilation congruence displayed the expected ventilation kinetics, while areas of ventilation mismatch displayed abnormally slow gas wash‐in and wash‐out. Conclusion In CF subjects, ventilation abnormalities are identified by both 19F and HP 129Xe imaging. However, these ventilation abnormalities are not entirely congruent. 19F and HP 129Xe imaging provide complementary information that enable differentiation of normally ventilated, slowly ventilated, and non‐ventilated regions in the lungs.
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Affiliation(s)
- Andrew McCallister
- Department of Physics and Astronomy, The University of North Carolina, Chapel Hill, NC, USA.,Biomedical Research Imaging Center, The University of North Carolina, Chapel Hill, NC, USA
| | - Sang Hun Chung
- Department of Biomedical Engineering, The University of North Carolina, Chapel Hill, NC, USA
| | - Michael Antonacci
- Department of Physics and Astronomy, The University of North Carolina, Chapel Hill, NC, USA.,Biomedical Research Imaging Center, The University of North Carolina, Chapel Hill, NC, USA
| | - Margret Z Powell
- Marsico Lung Institute/UNC Cystic Fibrosis Center, The University of North Carolina, Chapel Hill, NC, USA
| | - Agathe S Ceppe
- Marsico Lung Institute/UNC Cystic Fibrosis Center, The University of North Carolina, Chapel Hill, NC, USA
| | - Scott H Donaldson
- Marsico Lung Institute/UNC Cystic Fibrosis Center, The University of North Carolina, Chapel Hill, NC, USA.,Division of Pulmonary and Critical Care Medicine, The University of North Carolina, Chapel Hill, NC, USA
| | - Yueh Z Lee
- Department of Physics and Astronomy, The University of North Carolina, Chapel Hill, NC, USA.,Biomedical Research Imaging Center, The University of North Carolina, Chapel Hill, NC, USA.,Department of Biomedical Engineering, The University of North Carolina, Chapel Hill, NC, USA.,Marsico Lung Institute/UNC Cystic Fibrosis Center, The University of North Carolina, Chapel Hill, NC, USA.,Department of Radiology, The University of North Carolina, Chapel Hill, NC, USA
| | - Rosa Tamara Branca
- Department of Physics and Astronomy, The University of North Carolina, Chapel Hill, NC, USA.,Biomedical Research Imaging Center, The University of North Carolina, Chapel Hill, NC, USA
| | - Jennifer L Goralski
- Marsico Lung Institute/UNC Cystic Fibrosis Center, The University of North Carolina, Chapel Hill, NC, USA.,Division of Pulmonary and Critical Care Medicine, The University of North Carolina, Chapel Hill, NC, USA.,Division of Pediatric Pulmonology, The University of North Carolina, Chapel Hill, NC, USA
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16
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Haywood KB, Goralski JL. The specialist as primary care provider in CF. J Cyst Fibros 2020; 19:844-845. [PMID: 32335024 DOI: 10.1016/j.jcf.2020.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Kelsey B Haywood
- Marsico Lung Institute/UNC Cystic Fibrosis Center, The University of North Carolina at Chapel Hill, NC, United States
| | - Jennifer L Goralski
- Marsico Lung Institute/UNC Cystic Fibrosis Center, The University of North Carolina at Chapel Hill, NC, United States; Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, NC, United States; Division of Pediatric Pulmonology, The University of North Carolina at Chapel Hill, NC, United States.
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17
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Goralski JL, Chung SH, Glass TM, Ceppe AS, Akinnagbe-Zusterzeel EO, Trimble AT, Boucher RC, Soher BJ, Charles HC, Donaldson SH, Lee YZ. Dynamic perfluorinated gas MRI reveals abnormal ventilation despite normal FEV1 in cystic fibrosis. JCI Insight 2020; 5:133400. [PMID: 31855577 DOI: 10.1172/jci.insight.133400] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/10/2019] [Indexed: 11/17/2022] Open
Abstract
We hypothesized that dynamic perfluorinated gas MRI would sensitively detect mild cystic fibrosis (CF) lung disease. This cross-sectional study enrolled 20 healthy volunteers and 24 stable subjects with CF, including a subgroup of subjects with normal forced expiratory volume in the first second (FEV1; >80% predicted, n = 9). Dynamic fluorine-19-enhanced MRI (19F MRI) were acquired during sequential breath holds while breathing perfluoropropane (PFP) and during gas wash-out. Outcomes included the fraction of lung without significant ventilation (ventilation defect percent, VDP) and time constants that described PFP wash-in and wash-out kinetics. VDP values (mean ± SD) of healthy controls (3.87% ± 2.7%) were statistically different from moderate CF subjects (19.5% ± 15.5%, P = 0.001) but not from mild CF subjects (10.4% ± 9.9%, P = 0.24). In contrast, the fractional lung volume with slow gas wash-out was elevated both in subjects with mild (9.61% ± 4.87%; P = 0.0066) and moderate CF (16.01% ± 5.01%; P = 0.0002) when compared with healthy controls (3.84% ± 2.16%) and distinguished mild from moderate CF (P = 0.006). 19F MRI detected significant ventilation abnormalities in subjects with CF. The ability of gas wash-out kinetics to distinguish between healthy and mild CF lung disease subjects makes 19F MRI a potentially valuable method for the characterization of early lung disease in CF. This study has been registered at ClinicalTrials.gov (NCT03489590).
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Affiliation(s)
- Jennifer L Goralski
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine.,Marsico Lung Institute.,Division of Pediatric Pulmonology, Department of Pediatrics
| | | | - Tyler M Glass
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Agathe S Ceppe
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine.,Marsico Lung Institute
| | | | - Aaron T Trimble
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine.,Marsico Lung Institute
| | - Richard C Boucher
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine.,Marsico Lung Institute
| | - Brian J Soher
- Center for Advanced Magnetic Resonance Development and
| | - H Cecil Charles
- Duke Image Analysis Laboratory, Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Scott H Donaldson
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine.,Marsico Lung Institute
| | - Yueh Z Lee
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine.,Biomedical Research Imaging Center, and
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18
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Megalaa R, Gopalareddy V, Champion E, Goralski JL. Time for a gut check: Pancreatic sufficiency resulting from CFTR modulator use. Pediatr Pulmonol 2019; 54:E16-E18. [PMID: 31066218 DOI: 10.1002/ppul.24353] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/12/2019] [Accepted: 04/17/2019] [Indexed: 11/11/2022]
Abstract
Pancreatic exocrine insufficiency in cystic fibrosis is genetically determined and generally felt to be irreversible. However, recent studies in young children started on cystic fibrosis transmembrane conductance regulator (CFTR) modulators have suggested improvement of pancreatic functioning over time. Here, we present the case of a 10-year-old child with pancreatic exocrine insufficiency since birth who regained pancreatic functioning after 4 years on the CFTR corrector drug, ivacaftor.
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Affiliation(s)
- Rosemary Megalaa
- Division of Pediatric Pulmonology, Atrium Health, Levine Children's Hospital, Charlotte, NC
| | - Vani Gopalareddy
- Division of Pediatric Gastroenterology, Atrium Health, Levine Children's Hospital, Charlotte, NC
| | - Elizabeth Champion
- Division of Pediatric Pulmonology, Atrium Health, Levine Children's Hospital, Charlotte, NC
| | - Jennifer L Goralski
- Division of Pediatric Pulmonology, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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19
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Bernstein AT, Leigh MW, Goralski JL, Esther CR, McKinzie CJ. Use of telavancin in adolescent patients with cystic fibrosis and prior intolerance to vancomycin: A case series. J Cyst Fibros 2018; 17:e48-e50. [PMID: 30170755 DOI: 10.1016/j.jcf.2018.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/02/2018] [Accepted: 08/01/2018] [Indexed: 11/16/2022]
Abstract
The most common pathogen in pediatric cystic fibrosis (CF) patients is Staphylococcus aureus, and drug-resistant species are associated with negative outcomes. Methicillin-resistant Staphylococcus aureus (MRSA) is notoriously hard to treat because many antibiotics are not FDA approved for children and drug allergies or intolerances can prohibit the use of others. Telavancin is currently indicated for hospital-acquired pneumonia and ventilator-associated pneumonia caused by MRSA, but it has not been studied in patients with CF or in pediatrics. As a semi-synthetic derivative of vancomycin, it is unknown if cross-reactivity with telavancin occurs in patients with vancomycin hypersensitivity or intolerance. In this case series, we describe three adolescent patients with CF and previous intolerance to vancomycin who received telavancin for bronchopulmonary exacerbations.
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Affiliation(s)
- Adam T Bernstein
- Department of Pharmacy, University of North Carolina Medical Center, 101 Manning Drive, Campus Box 7600, Chapel Hill, NC 27514, United States
| | - Margaret W Leigh
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, 450-D MacNider Hall, Campus Box 7217, Chapel Hill, NC 27599-7217, United States
| | - Jennifer L Goralski
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, 450-D MacNider Hall, Campus Box 7217, Chapel Hill, NC 27599-7217, United States.; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, 125 MacNider Hall, Campus Box 7005, Chapel Hill, NC 27599-7005, United States
| | - Charles R Esther
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, 450-D MacNider Hall, Campus Box 7217, Chapel Hill, NC 27599-7217, United States
| | - Cameron J McKinzie
- Department of Pharmacy, University of North Carolina Medical Center, 101 Manning Drive, Campus Box 7600, Chapel Hill, NC 27514, United States..
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20
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Goralski JL, Wu D, Thelin WR, Boucher RC, Button B. The in vitro effect of nebulised hypertonic saline on human bronchial epithelium. Eur Respir J 2018; 51:13993003.02652-2017. [PMID: 29599187 DOI: 10.1183/13993003.02652-2017] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/28/2018] [Indexed: 11/05/2022]
Abstract
Inhaled hypertonic saline (HS) is an effective therapy for muco-obstructive lung diseases. However, the mechanism of action and principles pertinent to HS administration remain unclear.An in vitro system aerosolised HS to epithelial cells at rates comparable to in vivo conditions. Airway surface liquid (ASL) volume and cell height responses were measured by confocal microscopy under normal and hyperconcentrated mucus states.Aerosolised HS produced a rapid increase in ASL height and decrease in cell height. Added ASL volume was quickly reabsorbed following termination of nebulisation, although cell height did not recover within the same time frame. ASL volume responses to repeated HS administrations were blunted, but could be restored by a hypotonic saline bolus interposed between HS administrations. HS-induced ASL hydration was prolonged with hyperconcentrated mucus on the airway surface, with more modest reductions in cell volume.Aerosolised HS produced osmotically induced increases in ASL height that were limited by active sodium absorption and cell volume-induced reductions in cell water permeability. Mucus on airway surfaces prolonged the effect of HS via mucus-dependent osmotic forces, suggesting that the duration of action of HS is increased in patients with hyperconcentrated mucus.
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Affiliation(s)
- Jennifer L Goralski
- Cystic Fibrosis Research and Treatment Center/Marsico Lung Institute, Chapel Hill, NC, USA.,Division of Pulmonary and Critical Care Medicine, Dept of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Pediatric Pulmonology, Dept of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dan Wu
- Cystic Fibrosis Research and Treatment Center/Marsico Lung Institute, Chapel Hill, NC, USA
| | | | - Richard C Boucher
- Cystic Fibrosis Research and Treatment Center/Marsico Lung Institute, Chapel Hill, NC, USA.,Division of Pulmonary and Critical Care Medicine, Dept of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Brian Button
- Cystic Fibrosis Research and Treatment Center/Marsico Lung Institute, Chapel Hill, NC, USA.,Dept of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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21
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Goralski JL, Nasr SZ, Uluer A. Overcoming barriers to a successful transition from pediatric to adult care. Pediatr Pulmonol 2017; 52:S52-S60. [PMID: 28950427 DOI: 10.1002/ppul.23778] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/07/2017] [Indexed: 11/09/2022]
Abstract
As life expectancy for people with cystic fibrosis (CF) has increased dramatically, so has the need for a guided, structured transition from pediatric to adult-focused care. A formalized transition program allows for seamless transfer of patients between providers, helping to ensure continuity of care, and avoid potential declines associated with inconsistent medical care. New CF Center guidelines issued by the CFF strongly recommend that each center establish a transition program for age-appropriate transition to an adult CF clinic. In this article, we explore the remaining barriers to establishing a transition program in a CF Center and offer examples of several successful models. We describe CFF-sponsored and other initiatives that exist to support centers in establishing a transition program and discuss the need for ongoing research in this area.
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Affiliation(s)
- Jennifer L Goralski
- Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Samya Z Nasr
- Department of Pediatrics, University of Michigan Health System, Ann Arbor, Michigan
| | - Ahmet Uluer
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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McKinzie CJ, Goralski JL, Noah TL, Retsch-Bogart GZ, Prieur MB. Worsening anxiety and depression after initiation of lumacaftor/ivacaftor combination therapy in adolescent females with cystic fibrosis. J Cyst Fibros 2017; 16:525-527. [PMID: 28602538 DOI: 10.1016/j.jcf.2017.05.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
Abstract
In both phase III studies of LUM/IVA, as well as an extension study, worsening of mental health was not reported as a common side effect. Here we describe five cases in adolescent female patients that suggest a worsening of anxiety or depression associated with its use. In these five patients, two experienced suicidal ideation and three made suicide attempts that resulted in psychiatric hospitalizations.
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Affiliation(s)
- Cameron J McKinzie
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, United States.
| | - Jennifer L Goralski
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, United States; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Terry L Noah
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - George Z Retsch-Bogart
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Mary Beth Prieur
- Department of Psychiatry and Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, United States
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23
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Goralski JL, Davis SD. Improving complex medical care while awaiting next-generation CFTR potentiators and correctors: The current pipeline of therapeutics. Pediatr Pulmonol 2015; 50 Suppl 40:S66-73. [PMID: 26335956 DOI: 10.1002/ppul.23253] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 05/01/2015] [Revised: 06/18/2015] [Accepted: 06/22/2015] [Indexed: 11/06/2022]
Abstract
While a major target in cystic fibrosis (CF) research in recent years has been the development of corrector and potentiator drugs targeting the cystic fibrosis transmembrane conductance regulator (CFTR) protein, these therapies have not yet proven robust enough to replace or eliminate other therapies that have demonstrated improved health outcomes and quality of life in patients with CF. Further, ivacaftor is only indicated for approximately 5% of the US CF population, although the FDA has recently approved lumacaftor/ivacaftor, a combination therapy intended for those homozygous for Phe508del, which should reach a much larger number of patients. This review appraises therapeutics currently available or being studied while we await the next generation of CFTR potentiators and correctors.
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Affiliation(s)
- Jennifer L Goralski
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of Pediatric Pulmonology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie D Davis
- Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana
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24
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Hawkins A, Guttentag SH, Deterding R, Funkhouser WK, Goralski JL, Chatterjee S, Mulugeta S, Beers MF. A non-BRICHOS SFTPC mutant (SP-CI73T) linked to interstitial lung disease promotes a late block in macroautophagy disrupting cellular proteostasis and mitophagy. Am J Physiol Lung Cell Mol Physiol 2014; 308:L33-47. [PMID: 25344067 DOI: 10.1152/ajplung.00217.2014] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Mutation of threonine for isoleucine at codon 73 (I73T) in the human surfactant protein C (hSP-C) gene (SFTPC) accounts for a significant portion of SFTPC mutations associated with interstitial lung disease (ILD). Cell lines stably expressing tagged primary translation product of SP-C isoforms were generated to test the hypothesis that deposition of hSP-C(I73T) within the endosomal system promotes disruption of a key cellular quality control pathway, macroautophagy. By fluorescence microscopy, wild-type hSP-C (hSP-C(WT)) colocalized with exogenously expressed human ATP binding cassette class A3 (hABCA3), an indicator of normal trafficking to lysosomal-related organelles. In contrast, hSP-C(I73T) was dissociated from hABCA3 but colocalized to the plasma membrane as well as the endosomal network. Cells expressing hSP-C(I73T) exhibited increases in size and number of cytosolic green fluorescent protein/microtubule-associated protein 1 light-chain 3 (LC3) vesicles, some of which colabeled with red fluorescent protein from the gene dsRed/hSP-C(I73T). By transmission electron microscopy, hSP-C(I73T) cells contained abnormally large autophagic vacuoles containing organellar and proteinaceous debris, which phenocopied ultrastructural changes in alveolar type 2 cells in a lung biopsy from a SFTPC I73T patient. Biochemically, hSP-C(I73T) cells exhibited increased expression of Atg8/LC3, SQSTM1/p62, and Rab7, consistent with a distal block in autophagic vacuole maturation, confirmed by flux studies using bafilomycin A1 and rapamycin. Functionally, hSP-C(I73T) cells showed an impaired degradative capacity for an aggregation-prone huntingtin-1 reporter substrate. The disruption of autophagy-dependent proteostasis was accompanied by increases in mitochondria biomass and parkin expression coupled with a decrease in mitochondrial membrane potential. We conclude that hSP-C(I73T) induces an acquired block in macroautophagy-dependent proteostasis and mitophagy, which could contribute to the increased vulnerability of the lung epithelia to second-hit injury as seen in ILD.
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Affiliation(s)
- Arie Hawkins
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Susan H Guttentag
- Department of Pediatrics; Monroe Carell Jr. Children's Hospital, Vanderbilt University, Nashville, Tennessee
| | - Robin Deterding
- Department of Pediatrics; University of Colorado School of Medicine, Denver, Colorado
| | - William K Funkhouser
- Department of Pathology and Lab Medicine; University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer L Goralski
- Departments of Medicine and Pediatrics; University of North Carolina, Chapel Hill, North Carolina
| | - Shampa Chatterjee
- Institute for Environmental Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Surafel Mulugeta
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania;
| | - Michael F Beers
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
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25
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Goralski JL, Davis SD. Breathing easier: addressing the challenges of aerosolizing medications to infants and preschoolers. Respir Med 2014; 108:1069-74. [PMID: 25012949 DOI: 10.1016/j.rmed.2014.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/03/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
An increasing number of patients are dependent on aerosolized therapy to manage pulmonary diseases, including asthma, cystic fibrosis, and pulmonary arterial hypertension. An aerosol therapy is only useful if it can be appropriately and consistently delivered in the desired dose to the lower respiratory tract. Many factors affect this deposition in young children, including anatomical and physiologic differences between adults and children, patient-mask interface issues, the challenge of administering medication to uncooperative children, and behavioral adherence. Moreover, the techniques used to assess aerosol delivery to pediatric patients need to be carefully evaluated as new therapies and drug-device combinations are tested. In this review, we will address some of the challenges of delivering aerosolized medications to pediatric patients.
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Affiliation(s)
- Jennifer L Goralski
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Division of Pediatric Pulmonology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Stephanie D Davis
- James Whitcomb Riley Hospital for Children, Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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26
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27
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Abstract
An increasing number of medical conditions are chronically or acutely managed with some form of aerosolized therapy. Due to the benefit of directly administering medications to the intended site of action, there is great interest in evaluating treatments for aerosol use. One of the major challenges in selecting and testing new drug-device combinations in children is the uncertainty regarding the appropriate outcome measure to choose. In studies involving adult patients, typically exacerbations of disease or airflow obstruction are assessed as endpoints in drug trials or device assessment. However, in young children, choosing endpoints to assess efficacy is difficult due to the potential lack of sensitive, noninvasive endpoints that are easily performed across sites. In this review, we discuss the challenges and limitations of selecting clinical endpoints for drug-device trials in the youngest population, with a focus on novel emerging technologies. This article provides an overview of preschool and infant pulmonary function testing, multiple-breath washout, imaging techniques including computed tomography and magnetic resonance imaging, flexible bronchoscopy in children, mucociliary clearance scans, and exhaled breath condensate.
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Affiliation(s)
- Jennifer L Goralski
- 1 Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill , Chapel Hill, NC
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28
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Goralski JL, Lercher DM, Davis SD, Dellon ES. Eosinophilic esophagitis in cystic fibrosis: a case series and review of the literature. J Cyst Fibros 2012; 12:9-14. [PMID: 23085252 DOI: 10.1016/j.jcf.2012.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 07/16/2012] [Accepted: 09/17/2012] [Indexed: 12/19/2022]
Abstract
Patients with cystic fibrosis (CF) frequently experience gastrointestinal symptoms including nausea, emesis, malnutrition and indigestion; diseases such as gastroesophageal reflux disease (GERD), distal intestinal obstructive syndrome, and cholelithiasis are commonly implicated. We have recently diagnosed eosinophilic esophagitis (EoE) in three patients with CF. EoE is a TH-2 driven, allergen-mediated disease which causes esophageal eosinophilia and presents with symptoms of nausea, feeding intolerance, regurgitation, and dysphagia. EoE is diagnosed when esophageal biopsies reveal greater than 15 eosinophils per high power field in the setting of the appropriate clinical scenario and after exclusion of other causes of esophageal eosinophilia. Although described with increasing frequently in the gastrointestinal literature, there have been no prior cases documenting the co-existence of EoE and CF. We speculate that this is related to lack of familiarity with EoE symptoms by CF providers. We present three patients with CF diagnosed with EoE and review the current literature regarding diagnosis and management, focusing on management issues in patients with CF.
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Affiliation(s)
- Jennifer L Goralski
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, United States.
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29
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Goralski JL, Boucher RC, Button B. Osmolytes and ion transport modulators: new strategies for airway surface rehydration. Curr Opin Pharmacol 2010; 10:294-9. [PMID: 20439165 DOI: 10.1016/j.coph.2010.04.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 04/06/2010] [Indexed: 10/19/2022]
Abstract
Mucociliary clearance (MCC) in CF lung disease is limited by airway dehydration, leading to persistent bacterial infection and inflammation in the airways. Agents designed to rehydrate the airway mucosa lead to improved MCC. Hyperosmolar agents, such as hypertonic saline and mannitol, create a luminal osmotic gradient, drawing water into the dehydrated ASL. Ion transport modulators function to activate alternative chloride channels and/or to block sodium hyperabsorption that occurs through a dysregulated ENaC channel. Combinations of these therapies may result in a synergistic improvement in airway hydration, and thus, restore MCC. Active ongoing phase II and III trials of new pharmacotherapeutics are covered in this review.
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Affiliation(s)
- Jennifer L Goralski
- Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, 130 Mason Farm Road, CB#7020, Chapel Hill, NC 27599-7020, United States
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30
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Goralski JL, Bromberg PA, Haithcock B. Intrapleural hemorrhage after administration of tPA: a case report and review of the literature. Ther Adv Respir Dis 2010; 3:295-300. [PMID: 19934281 DOI: 10.1177/1753465809350748] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Intrapleural fibrinolytic enzymes have been used for over 60 years in the treatment of complicated pleural effusions to lyse loculations and promote resolution. Despite this extensive history of use, however, little is known about complications that may arise with the use of this therapy. Here we discuss a patient with chronic renal failure on hemodialysis who developed an intrapleural hemorrhage after the administration of intrapleural tPA to treat a complicated parapneumonic effusion. A review of the literature examines the efficacy and safety of this therapy, focusing on bleeding complications. Specific attention is paid to patients who have underlying coagulopathies or who are receiving anticoagulation. DATA SOURCES A review of the literature, as indexed in PubMed, was undertaken using the following search terms in combination: tPA, pleural effusion, complications of thrombolytics, and intrapleural hemorrhage. The search was inclusive of patients under the age of 18, but was limited by English language and human subjects. STUDY SELECTION/DATA EXTRACTION All relevant articles identified during the search were reviewed. Those studies that reported on bleeding complications, or lack thereof, were included in this review. Limitations of each article are noted in the text. CONCLUSIONS Multiple studies, including a 2000 ACP consensus statement and a 2008 Cochrane review, indicate the need for further investigations to evaluate the safety and efficacy of intrapleural thrombolytics for the treatment of complicated pleural effusions and empyemas. Limited studies specifically address bleeding complications, especially in subpopulations of patients receiving concurrent anticoagulant therapy.
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Affiliation(s)
- Jennifer L Goralski
- University of North Carolina at Chapel Hill, Division of Pulmonary and Critical Care Medicine, Chapel Hill, NC, USA.
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Affiliation(s)
- Alfonso H Waller
- Department of Medicine, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey, USA
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