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Abstract
Diet plays an important role in human health and disease. Of all human diseases, diarrheal illnesses bring diet into sharp focus as it has a direct causal and therapeutic relationship. With the advent and widespread use of next generation sequencing, significant advances have been made in unraveling the etiologies of congenital diarrheas and enteropathies, some of which are eminently treatable with dietary modification. Early institution of appropriate dietary therapy is lifesaving in congenital osmotic diarrheas. Chronic diarrhea in older children and adolescents often have an underlying dietary basis, depending on the etiology. Identification and exclusion of the offending food in the diet results in dramatic improvement in symptoms. It is equally important to be prudent and cautious in the use of exclusion diets in management of chronic diarrhea as it is associated with micronutrient deficiencies, needless escalation of cost and enable maladaptive food intake behaviors. In this review, authors discuss etiology specific dietary management of diarrhea in children with emphasis on congenital diarrheas and enteropathies.
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Affiliation(s)
- Sahana Shankar
- Division of Pediatric Gastroenterology, Department of Pediatrics, Mazumdar Shaw Medical Center, Narayana Health, Bangalore, India.
| | - Emmany Durairaj
- Department of Clinical Nutrition and Dietetics, Mazumdar Shaw Medical Center, Narayana Health, Bangalore, India
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2
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Hicks SD. The role of primary care clinicians in detecting and managing cystic fibrosis: A commentary on Advancing Early Identification of Cystic Fibrosis through Newborn Screening. Curr Probl Pediatr Adolesc Health Care 2024:101638. [PMID: 38797571 DOI: 10.1016/j.cppeds.2024.101638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Affiliation(s)
- Steven D Hicks
- Penn State College of Medicine, Department of Pediatrics, 500 University Drive, Hershey, PA 17033, USA.
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3
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McDonald CM, Reid EK, Pohl JF, Yuzyuk TK, Padula LM, Vavrina K, Altman K. Cystic fibrosis and fat malabsorption: Pathophysiology of the cystic fibrosis gastrointestinal tract and the impact of highly effective CFTR modulator therapy. Nutr Clin Pract 2024; 39 Suppl 1:S57-S77. [PMID: 38429959 DOI: 10.1002/ncp.11122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/28/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Cystic fibrosis (CF) is a progressive, genetic, multi-organ disease affecting the respiratory, digestive, endocrine, and reproductive systems. CF can affect any aspect of the gastrointestinal (GI) tract, including the esophagus, stomach, small intestine, colon, pancreas, liver, and gall bladder. GI pathophysiology associated with CF results from CF membrane conductance regulator (CFTR) dysfunction. The majority of people with CF (pwCF) experience exocrine pancreatic insufficiency resulting in malabsorption of nutrients and malnutrition. Additionally, other factors can cause or worsen fat malabsorption, including the potential for short gut syndrome with a history of meconium ileus, hepatobiliary diseases, and disrupted intraluminal factors, such as inadequate bile salts, abnormal pH, intestinal microbiome changes, and small intestinal bacterial overgrowth. Signs and symptoms associated with fat malabsorption, such as abdominal pain, bloating, malodorous flatus, gastroesophageal reflux, nausea, anorexia, steatorrhea, constipation, and distal intestinal obstruction syndrome, are seen in pwCF despite the use of pancreatic enzyme replacement therapy. Given the association of poor nutrition status with lung function decline and increased mortality, aggressive nutrition support is essential in CF care to optimize growth in children and to achieve and maintain a healthy body mass index in adults. The introduction of highly effective CFTR modulator therapy and other advances in CF care have profoundly changed the course of CF management. However, GI symptoms in some pwCF may persist. The use of current knowledge of the pathophysiology of the CF GI tract as well as appropriate, individualized management of GI symptoms continue to be integral components of care for pwCF.
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Affiliation(s)
| | - Elizabeth K Reid
- Cystic Fibrosis Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John F Pohl
- Pediatric Gastroenterology, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Tatiana K Yuzyuk
- Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
- ARUP Institute for Clinical & Experimental Pathology, Salt Lake City, Utah, USA
| | - Laura M Padula
- Pediatric Specialty, University Health, San Antonio, Texas, USA
| | - Kay Vavrina
- Pediatric Specialty, University Health, San Antonio, Texas, USA
| | - Kimberly Altman
- Gunnar Esiason Adult Cystic Fibrosis and Lung Center, Columbia University Medical Center, New York, New York, USA
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4
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Kopp BT, Ross SE, Bojja D, Guglani L, Chandler JD, Tirouvanziam R, Thompson M, Slaven JE, Chmiel JF, Siracusa C, Sanders DB. Nasal airway inflammatory responses and pathogen detection in infants with cystic fibrosis. J Cyst Fibros 2024; 23:219-225. [PMID: 37977937 DOI: 10.1016/j.jcf.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/28/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Detecting airway inflammation non-invasively in infants with cystic fibrosis (CF) is difficult. We hypothesized that markers of inflammation in CF [IL-1β, IL-6, IL-8, IL-10, IL-17A, neutrophil elastase (NE) and tumor necrosis factor (TNF-α)] could be measured in infants with CF from nasal fluid and would be elevated during viral infections or clinician-defined pulmonary exacerbations (PEx). METHODS We collected nasal fluid, nasal swabs, and hair samples from 34 infants with CF during monthly clinic visits, sick visits, and hospitalizations. Nasal fluid was isolated and analyzed for cytokines. Respiratory viral detection on nasal swabs was performed using the Luminex NxTAG® Respiratory Pathogen Panel. Hair samples were analyzed for nicotine concentration by reverse-phase high-performance liquid chromatography. We compared nasal cytokine concentrations between the presence and absence of detected respiratory viruses, PEx, and smoke exposure. RESULTS A total of 246 samples were analyzed. Compared to measurements in the absence of respiratory viruses, mean concentrations of IL-6, IL-8, TNF-α, and NE were significantly increased while IL-17A was significantly decreased in infants positive for respiratory viruses. IL-17A was significantly decreased and NE increased in those with a PEx. IL-8 and NE were significantly increased in infants with enteric pathogen positivity on airway cultures, but not P. aeruginosa or S. aureus. Compared to those with no smoke exposure, there were significantly higher levels of IL-6, IL-10, and NE in infants with detectable levels of nicotine. CONCLUSIONS Noninvasive collection of nasal fluid may identify inflammation in infants with CF during changing clinical or environmental exposures.
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Affiliation(s)
- Benjamin T Kopp
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sydney E Ross
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dinesh Bojja
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Lokesh Guglani
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Joshua D Chandler
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Rabindra Tirouvanziam
- Division of Pulmonology, Asthma, Cystic Fibrosis, and Sleep, Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Misty Thompson
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - James E Slaven
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - James F Chmiel
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher Siracusa
- Division of Pulmonary Medicine, Cincinnati Children's Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Don B Sanders
- Department of Pediatrics, Riley Hospital for Children at IU Health, Indiana University School of Medicine, Indianapolis, IN, USA.
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5
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De Wachter E, De Boeck K, Sermet-Gaudelus I, Simmonds NJ, Munck A, Naehrlich L, Barben J, Boyd C, Veen SJ, Carr SB, Fajac I, Farrell PM, Girodon E, Gonska T, Grody WW, Jain M, Jung A, Kerem E, Raraigh KS, van Koningsbruggen-Rietschel S, Waller MD, Southern KW, Castellani C. ECFS standards of care on CFTR-related disorders: Towards a comprehensive program for affected individuals. J Cyst Fibros 2024:S1569-1993(24)00011-0. [PMID: 38388234 DOI: 10.1016/j.jcf.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024]
Abstract
After three publications defining an updated guidance on the diagnostic criteria for people with cystic fibrosis transmembrane conductance regulator (CFTR)-related disorders (pwCFTR-RDs), establishing its relationship to CFTR-dysfunction and describing the individual disorders, this fourth and last paper in the series addresses some critical challenges facing health care providers and pwCFTR-RD. Topics included are: 1) benefits and obstacles to collect data from pwCFTR-RD are discussed, together with the opportunity to integrate them into established CF-registries; 2) the potential of infants designated CRMS/CFSPID to develop a CFTR-RD and how to communicate this information; 3) a description of the challenges in genetic counseling, with particular regard to phenotypic variability, unknown long-term evolution, CFTR testing and pregnancy termination 4) a proposal for the assessment of potential barriers to the implementation and dissemination of the produced documents to health care professionals involved in the care of pwCFTR-RD and a process to monitor the implementation of the CFTR-RD recommendations; 5) clinical trials investigating the efficacy of CFTR modulators in CFTR-RD and how endpoints and outcomes might be adapted to the heterogeneity of these disorders.
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Affiliation(s)
- E De Wachter
- Cystic Fibrosis Center, Pediatric Pulmonology department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
| | - K De Boeck
- Department of Pediatrics, University of Leuven, Leuven, Belgium
| | - I Sermet-Gaudelus
- INSERM U1151, Institut Necker Enfants Malades, Paris, France; Université de Paris, Paris, France; Centre de référence Maladies Rares, Mucoviscidose et maladies apparentées. Hôpital Necker Enfants malades, Paris, France
| | - N J Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital and Imperial College, London, UK
| | - A Munck
- Paediatric Cystic Fibrosis centre, Hôpital Necker Enfants Malades, AP-HP Paris, France
| | - L Naehrlich
- Department of Pediatrics, Justus-Liebig-University Giessen, Germany
| | - J Barben
- Paediatric Pulmonology & CF Centre, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | | | | | - S B Carr
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, and Imperial College, London, UK
| | - I Fajac
- Assistance Publique-Hôpitaux de Paris, Thoracic Department and National Cystic Fibrosis Reference Centre, Cochin Hospital, 75014 Paris, France; Université Paris Cité, Inserm U1016, Institut Cochin, 75014 Paris, France
| | - P M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | - E Girodon
- Service de Médecine Génomique des Maladies de Système et d'Organe, APHP.Centre - Université de Paris Cité, Hôpital Cochin, Paris, France
| | - T Gonska
- Division of Pediatric Gastroenterology, Hepatology, Nutrition, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Program of Translational Medicine, Research institute, Hospital for Sick Children, Toronto, Canada
| | - W W Grody
- Departments of Pathology & Laboratory Medicine, Pediatrics, and Human Genetics, UCLA School of Medicine, Los Angeles, California 90095-1732, USA
| | - M Jain
- Northwestern University Feinberg School of Medicine, Pulmonary Critical Care, Chicago, Illinois, United States
| | - A Jung
- University Children`s Hospital Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland
| | - E Kerem
- Department of Pediatrics and CF Center, Hadassah Hebrew University medical Center, Jerusalem, Israel
| | - K S Raraigh
- Department of Genetic Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | | | - M D Waller
- Department of Adult Cystic Fibrosis and Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; Centre for Human & Applied Physiological Sciences, King's College London, London, United Kingdom
| | - K W Southern
- Department of Women's and Children's Health, University of Liverpool, Alder Hey Children's Hospital, Liverpool, UK
| | - C Castellani
- IRCCS Istituto Giannina Gaslini, Cystic Fibrosis Center, Genoa, Italy
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6
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Wilschanski M, Munck A, Carrion E, Cipolli M, Collins S, Colombo C, Declercq D, Hatziagorou E, Hulst J, Kalnins D, Katsagoni CN, Mainz JG, Ribes-Koninckx C, Smith C, Smith T, Van Biervliet S, Chourdakis M. ESPEN-ESPGHAN-ECFS guideline on nutrition care for cystic fibrosis. Clin Nutr 2024; 43:413-445. [PMID: 38169175 DOI: 10.1016/j.clnu.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Nutritional status is paramount in Cystic Fibrosis (CF) and is directly correlated with morbidity and mortality. The first ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with CF were published in 2016. An update to these guidelines is presented. METHODS The study was developed by an international multidisciplinary working group in accordance with officially accepted standards. Literature since 2016 was reviewed, PICO questions were discussed and the GRADE system was utilized. Statements were discussed and submitted for on-line voting by the Working Group and by all ESPEN members. RESULTS The Working Group updated the nutritional guidelines including assessment and management at all ages. Supplementation of vitamins and pancreatic enzymes remains largely the same. There are expanded chapters on pregnancy, CF-related liver disease, and CF-related diabetes, bone disease, nutritional and mineral supplements, and probiotics. There are new chapters on nutrition with highly effective modulator therapies and nutrition after organ transplantation.
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Affiliation(s)
- Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Anne Munck
- Cystic Fibrosis Centre, Hopital Necker-Enfants Malades, AP-HP, Paris, France
| | - Estefania Carrion
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marco Cipolli
- Cystic Fibrosis Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sarah Collins
- CF Therapies Team, Royal Brompton & Harefield Hospital, London, UK
| | - Carla Colombo
- University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Dimitri Declercq
- Cystic Fibrosis Reference Centre, Ghent University Hospital and Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Elpis Hatziagorou
- Cystic Fibrosis Unit, 3rd Pediatric Dept, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics and Department of Nutritional Sciences, The University of Toronto, Toronto, Canada
| | - Daina Kalnins
- Department of Clinical Dietetics, The Hospital for Sick Children, Toronto, Canada
| | - Christina N Katsagoni
- Department of Clinical Nutrition, Agia Sofia Children's Hospital, Athens, Greece; EFAD, European Specialist Dietetic Networks (ESDN) for Gastroenterology, Denmark
| | - Jochen G Mainz
- Brandenburg Medical School, University Hospital. Klinikum Westbrandenburg, Brandenburg an der Havel, Germany
| | - Carmen Ribes-Koninckx
- Pediatric Gastroenterology and Paediatric Cystic Fibrosis Unit. La Fe Hospital & La Fe Research Institute, Valencia, Spain
| | - Chris Smith
- Department of Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
| | - Thomas Smith
- Independent Patient Consultant Working at Above-disease Level, UK
| | | | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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7
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Squires JE, Raghu VK, Mazariegos GV. Optimizing the pediatric transplant candidate. Curr Opin Organ Transplant 2024; 29:43-49. [PMID: 37823752 DOI: 10.1097/mot.0000000000001115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW Advances in pediatric transplant parallel those in adult populations; however, there remain critical unique considerations and differences that require specialized knowledge and a specific skill set to optimize care afforded to the pediatric transplant candidate. We introduce general themes regarding optimization of the transplant candidate that are unique to children. RECENT FINDINGS The pathologies leading to pediatric organ transplant candidacy differ from adults and a precise understanding of the physiologies and natural histories of such diseases is critical for optimized care. Regardless of etiology, comorbidities including malnutrition, sarcopenia, and developmental delay are seen and often require disease and organ specific approaches to management. Additionally, an understanding of the concepts of developmental immunology and their relevance to transplant is critical. SUMMARY When looking to optimize pretransplant care, awareness of the pediatric-specific challenges by the transplant community in addition to organ- and age-specific management strategies enable the best outcomes for children awaiting solid organ transplantation.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh
| | - Vikram K Raghu
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh
| | - George V Mazariegos
- Thomas E. Starzl Transplantation Institute, Hillman Center for Pediatric Transplantation, Department of Transplant Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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8
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Southern KW, Addy C, Bell SC, Bevan A, Borawska U, Brown C, Burgel PR, Button B, Castellani C, Chansard A, Chilvers MA, Davies G, Davies JC, De Boeck K, Declercq D, Doumit M, Drevinek P, Fajac I, Gartner S, Georgiopoulos AM, Gursli S, Gramegna A, Hansen CM, Hug MJ, Lammertyn E, Landau EEC, Langley R, Mayer-Hamblett N, Middleton A, Middleton PG, Mielus M, Morrison L, Munck A, Plant B, Ploeger M, Bertrand DP, Pressler T, Quon BS, Radtke T, Saynor ZL, Shufer I, Smyth AR, Smith C, van Koningsbruggen-Rietschel S. Standards for the care of people with cystic fibrosis; establishing and maintaining health. J Cyst Fibros 2024; 23:12-28. [PMID: 38129255 DOI: 10.1016/j.jcf.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
This is the second in a series of four papers updating the European Cystic Fibrosis Society (ECFS) standards for the care of people with CF. This paper focuses on establishing and maintaining health. The guidance is produced using an evidence-based framework and with wide stakeholder engagement, including people from the CF community. Authors provided a narrative description of their topic and statements, which were more directive. These statements were reviewed by a Delphi exercise, achieving good levels of agreement from a wide group for all statements. This guidance reinforces the importance of a multi-disciplinary CF team, but also describes developing models of care including virtual consultations. The framework for health is reinforced, including the need for a physically active lifestyle and the strict avoidance of all recreational inhalations, including e-cigarettes. Progress with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy is reviewed, including emerging adverse events and advice for dose reduction and interruption. This paper contains guidance that is pertinent to all people with CF regardless of age and eligibility for and access to modulator therapy.
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Affiliation(s)
- Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK.
| | - Charlotte Addy
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Cardiff and Vale University Health Board, Cardiff, UK
| | - Scott C Bell
- Department of Thoracic Medicine and Faculty of Medicine, The University of Queensland, The Prince Charles Hospital, Brisbane, Australia
| | - Amanda Bevan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Urzula Borawska
- Institute of Mother and Child in Warsaw, Cystic Fibrosis Department and Dziekanow Lesny Hospital, Cystic Fibrosis Center, Dziekanow Lesny, Poland
| | - Catherine Brown
- West Midlands Adult CF Centre, Heartlands Hospital Birmingham, UK
| | - Pierre-Régis Burgel
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP) and Université Paris-Cité, Institut Cochin, Inserm U1016, Paris, France
| | - Brenda Button
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia 3181, and Department of Respiratory Medicine, Alfred Health, Melbourne 3004, Australia
| | - Carlo Castellani
- IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147 Genova, Italy
| | - Audrey Chansard
- Epigenetics and Cell Fate Centre, UMR7216 CNRS, Université Paris Cité, Paris, France, and Cystic Fibrosis Europe, Brussels, Belgium
| | - Mark A Chilvers
- Divison of Pediatric Respiratroy Medicine, BC Childrens Hospital, Vancouver, Canada
| | - Gwyneth Davies
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London; Imperial Biomedical Research Centre; Royal Brompton Hospital, Guy's & St Thomas' Trust, London, UK
| | | | - Dimitri Declercq
- Cystic Fibrosis Reference Center, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium; Department of Pediatrics, Center for children and adolescents with diabetes, Ghent University Hospital, Ghent, Belgium; Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | | | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Isabelle Fajac
- Assistance Publique - Hôpitaux de Paris, Université Paris Cité, Paris, France
| | | | - Anna M Georgiopoulos
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Sandra Gursli
- National Resource Centre for Cystic Fibrosis, Oslo University Hospital, Oslo, Norway
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Carina Me Hansen
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, the Netherlands
| | - Martin J Hug
- Medical Center - University of Freiburg, Pharmacy, Hugstetter St. 55, Freiburg, D-79106, Germany
| | - Elise Lammertyn
- Cystic Fibrosis Europe, Brussels, Belgium and the Belgian CF Association, Brussels, Belgium
| | - Edwina Eddie C Landau
- The Graub CF Center, Pulmonary Institute, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Ross Langley
- Department of Paediatric Respiratory & Sleep Medicine, Royal Hospital for Children, Glasgow, UK
| | - Nicole Mayer-Hamblett
- Seattle Children's Research Institute, Seattle, WA and Department of Pediatrics, University of Washington, Seattle, Wa, USA
| | - Anna Middleton
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Peter G Middleton
- Westmead Clinical School, University of Sydney and CITRICA, Dept Respiratory & Sleep Medicine, Westmead Hospital, Westmead, Australia
| | - Monika Mielus
- Cystic Fibrosis Department, Institute of Mother and Child, Warsaw, Poland; Cystic Fibrosis Centre, Pediatric Hospital, Dziekanów Leśny, Poland
| | - Lisa Morrison
- West of Scotland Adult CF Centre, Queen Elizabeth University Hospital, Glasgow, UK
| | - Anne Munck
- Hospital Necker Enfants-Malades, AP-HP, CF centre, Université Paris Descartes, Paris, France
| | - Barry Plant
- Cork Centre for Cystic Fibrosis (3CF), Cork University Hospital, Cork, Ireland
| | | | - Dominique Pougheon Bertrand
- Laboratoire Educations et Promotion de la santé, LEPS, UR 3412, University of Sorbonne Paris Nord, F-93430, Villetaneuse, France
| | | | - Bradley S Quon
- Division of Respiratory Medicine, Department of Medicine. St. Paul's Hospital and the University of British Columbia. Vancouver, British Columbia, Canada
| | - Thomas Radtke
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Zoe L Saynor
- Physical Activity, Health and Rehabilitation Thematic Research Group, School of Sport, Health and Exercise Science, Faculty of Science and Health, University of Portsmouth, UK and Wessex Cystic Fibrosis Unit, University Hospitals Southampton NHS Foundation Trust, UK
| | - Ilan Shufer
- CF Patient, Head of Access, Off label and Trials, Computer Science Architecture, Research and Innovation, Cystic Fibrosis Foundation of Israel, Israel
| | - Alan R Smyth
- School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast and NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Chris Smith
- Department of Nutrition and Dietetics, Royal Alexandra Children's Hospital, Brighton, UK
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9
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Hanaoka J. Future expectations for respiratory disease assessment in dynamic chest radiography. J Thorac Dis 2023; 15:7159-7161. [PMID: 38249901 PMCID: PMC10797365 DOI: 10.21037/jtd-23-1394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/13/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Jun Hanaoka
- Division of General Thoracic Surgery, Department of Surgery, Shiga University of Medical Science, Otsu, Japan
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10
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Gramegna A, Misuraca S, Lombardi A, Premuda C, Barone I, Ori M, Amati F, Retucci M, Nazzari E, Alicandro G, Ferrarese M, Codecasa L, Bandera A, Aliberti S, Daccò V, Blasi F. Treatable traits and challenges in the clinical management of non-tuberculous mycobacteria lung disease in people with cystic fibrosis. Respir Res 2023; 24:316. [PMID: 38104098 PMCID: PMC10725605 DOI: 10.1186/s12931-023-02612-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023] Open
Abstract
INTRODUCTION Over the last ten years an increasing prevalence and incidence of non-tuberculous mycobacteria (NTM) has been reported among patients with cystic fibrosis (CF) Viviani (J Cyst Fibros, 15(5):619-623, 2016). NTM pulmonary disease has been associated with negative clinical outcomes and often requires pharmacological treatment. Although specific guidelines help clinicians in the process of diagnosis and clinical management, the focus on the multidimensional assessment of concomitant problems is still scarce. MAIN BODY This review aims to identify the treatable traits of NTM pulmonary disease in people with CF and discuss the importance of a multidisciplinary approach in order to detect and manage all the clinical and behavioral aspects of the disease. The multidisciplinary complexity of NTM pulmonary disease in CF requires careful management of respiratory and extra-respiratory, including control of comorbidities, drug interactions and behavioral factors as adherence to therapies. CONCLUSIONS The treatable trait strategy can help to optimize clinical management through systematic assessment of all the aspects of the disease, providing a holistic treatment for such a multi-systemic and complex condition.
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Affiliation(s)
- Andrea Gramegna
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy.
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
| | - Sofia Misuraca
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Andrea Lombardi
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Premuda
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Ivan Barone
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Margherita Ori
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Mariangela Retucci
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
- Healthcare Professions Department, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Erica Nazzari
- Cystic Fibrosis Center, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy
| | - Gianfranco Alicandro
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Maurizio Ferrarese
- Regional TB Reference Centre, Villa Marelli Institute, Niguarda Hospital, Milan, Italy
| | - Luigi Codecasa
- Regional TB Reference Centre, Villa Marelli Institute, Niguarda Hospital, Milan, Italy
| | - Alessandra Bandera
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Valeria Daccò
- Cystic Fibrosis Center, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Via Francesco Sforza 35, 20122, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
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11
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Martiniano SL, Wu R, Farrell PM, Ren CL, Sontag MK, Elbert A, McColley SA. Late Diagnosis in the Era of Universal Newborn Screening Negatively Affects Short- and Long-Term Growth and Health Outcomes in Infants with Cystic Fibrosis. J Pediatr 2023; 262:113595. [PMID: 37406853 DOI: 10.1016/j.jpeds.2023.113595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/19/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
Newborn screening for cystic fibrosis was fully implemented in the US by 2010, but delays in timeliness of evaluation for infants with positive newborn screening tests persist. Through evaluation of national patient registry data, we determined that late initiation of cystic fibrosis care is associated with poorer long-term nutritional outcomes.
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Affiliation(s)
- Stacey L Martiniano
- University of Colorado School of Medicine, Aurora, CO; Breathing Institute, Children's Hospital Colorado, Aurora, CO.
| | - Runyu Wu
- Cystic Fibrosis Foundation, Bethesda, MD
| | - Philip M Farrell
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Clement L Ren
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Children's Hospital of Philadelphia, Division of Pulmonary and Sleep Medicine, Philadelphia, PA
| | - Marci K Sontag
- Center for Public Health Innovation, CI International, Littleton, CO
| | | | - Susanna A McColley
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL
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12
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Huang L, Lai HJ, Song J, Zhao Z, Lu Q, Murali SG, Brown DM, Worthey EA, Farrell PM. Impact of intrinsic and extrinsic risk factors on early-onset lung disease in cystic fibrosis. Pediatr Pulmonol 2023; 58:3071-3082. [PMID: 37539852 PMCID: PMC10592256 DOI: 10.1002/ppul.26625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/27/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Although respiratory pathology is known to develop in young children with cystic fibrosis (CF), the determinants of early-onset lung disease have not been elucidated. OBJECTIVE We aimed to determine the impact of potential intrinsic and extrinsic risk factors during the first 3 years of life, testing the hypothesis that both contribute significantly to early-onset CF lung disease. DESIGN We studied 104 infants born during 2012-2017, diagnosed through newborn screening by age 3 months, and evaluated comprehensively to 36 months of age. Lung disease manifestations were quantified with a new scoring system known as CFELD for Cystic Fibrosis Early-onset Lung Disease. The variants in the cystic fibrosis transmembrane conductance regulator (CFTR) gene were determined and categorized. Whole genome sequencing was performed on each subject and the data transformed to polygenic risk scores (PRS) that aggregate variants associated with lung function. Extrinsic factors included socioeconomic status (SES) indicators and environmental experiences such as exposures to smoking, pets, and daycare. RESULTS We found by univariate analysis that CFTR genotype and genetic modifiers aggregated by the PRS method were significantly associated with early-onset CF lung disease. Ordinal logistic regression analysis demonstrated that high and stable SES (maternal education ≥community college, stable 2-parent home, and not receiving Medicaid) and better growth (weight-for-age and height-for-age z-scores) reduced risks, while exposure to smoking and daycare ≥20 h/week increased the risk of CFELD severity. CONCLUSIONS Extrinsic, modifiable determinants are influential early and potentially as important as the intrinsic risk factors in the onset of CF lung disease.
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Affiliation(s)
- Leslie Huang
- Department of Pediatrics, University of Wisconsin – Madison, Madison, Wisconsin, USA
| | - HuiChuan J. Lai
- Department of Pediatrics, University of Wisconsin – Madison, Madison, Wisconsin, USA
- Department of Nutritional Sciences, University of Wisconsin – Madison, Madison, Wisconsin, USA
- Department of Population Health Sciences, University of Wisconsin – Madison, Madison, Wisconsin, USA
| | - Jie Song
- Department of Statistics, University of Wisconsin – Madison, Madison, Wisconsin, USA
| | - Zijie Zhao
- Department of Statistics, University of Wisconsin – Madison, Madison, Wisconsin, USA
| | - Qiongshi Lu
- Department of Statistics, University of Wisconsin – Madison, Madison, Wisconsin, USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin – Madison, Madison, Wisconsin, USA
| | - Sangita G. Murali
- Department of Nutritional Sciences, University of Wisconsin – Madison, Madison, Wisconsin, USA
| | - Donna M. Brown
- Departments of Pediatrics and Genetics, Center for Computational Genomics and Data Science at the UAB Marnix E. Heersink School of Medicine, Birmingham, AL, USA
| | - Elizabeth A. Worthey
- Departments of Pediatrics and Genetics, Center for Computational Genomics and Data Science at the UAB Marnix E. Heersink School of Medicine, Birmingham, AL, USA
| | - Philip M. Farrell
- Department of Pediatrics, University of Wisconsin – Madison, Madison, Wisconsin, USA
- Department of Population Health Sciences, University of Wisconsin – Madison, Madison, Wisconsin, USA
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Patel D, Baliss M, Saikumar P, Numan L, Teckman J, Hachem C. A Gastroenterologist's Guide to Care Transitions in Cystic Fibrosis from Pediatrics to Adult Care. Int J Mol Sci 2023; 24:15766. [PMID: 37958749 PMCID: PMC10648514 DOI: 10.3390/ijms242115766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/04/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Cystic Fibrosis is a chronic disease affecting multiple systems, including the GI tract. Clinical manifestation in patients can start as early as infancy and vary across different age groups. With the advent of new, highly effective modulators, the life expectancy of PwCF has improved significantly. Various GI aspects of CF care, such as nutrition, are linked to an overall improvement in morbidity, lung function and the quality of life of PwCF. The variable clinical presentations and management of GI diseases in pediatrics and adults with CF should be recognized. Therefore, it is necessary to ensure efficient transfer of information between pediatric and adult providers for proper continuity of management and coordination of care at the time of transition. The transition of care is a challenging process for both patients and providers and currently there are no specific tools for GI providers to help ensure a smooth transition. In this review, we aim to highlight the crucial features of GI care at the time of transition and provide a checklist that can assist in ensuring an effective transition and ease the challenges associated with it.
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Affiliation(s)
- Dhiren Patel
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children’s Medical Center, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (P.S.); (J.T.)
- The AHEAD Institute, Saint Louis University School of Medicine, St. Louis, MO 63104, USA
| | - Michelle Baliss
- Department of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (M.B.); (L.N.); (C.H.)
| | - Pavithra Saikumar
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children’s Medical Center, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (P.S.); (J.T.)
| | - Laith Numan
- Department of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (M.B.); (L.N.); (C.H.)
| | - Jeffrey Teckman
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cardinal Glennon Children’s Medical Center, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (P.S.); (J.T.)
| | - Christine Hachem
- Department of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO 63104, USA; (M.B.); (L.N.); (C.H.)
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Sankararaman S, Schindler T. Exocrine Pancreatic Insufficiency in Children - Challenges in Management. Pediatric Health Med Ther 2023; 14:361-378. [PMID: 37908317 PMCID: PMC10615098 DOI: 10.2147/phmt.s402589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/13/2023] [Indexed: 11/02/2023] Open
Abstract
Cystic fibrosis (CF) is the leading etiology for exocrine pancreatic insufficiency (EPI) in children, followed by chronic pancreatitis, Shwachman-Diamond syndrome, and other genetic disorders. Management of EPI in children poses several unique challenges such as difficulties in early recognition, lack of widespread availability of diagnostic tests and limited number of pediatric-specific pancreatic centers. Pancreatic enzyme replacement therapy is the cornerstone of EPI management and in young children difficulties in administering pancreatic enzymes are frequently encountered. Patients with EPI also should be screened for fat-soluble vitamin deficiencies and receive appropriate supplementation. Among disorders with EPI in children, CF is the relatively well-studied condition, and most management recommendations for EPI in children come from expert consensus and conventional practice guidelines. The impact of EPI can be greater in children given their high metabolic demands and rapid growth. Early diagnosis and aggressive management of EPI prevent consequences of complications such as malnutrition, fat-soluble vitamin deficiencies, and poor bone health and improve outcomes. Management by multi-disciplinary team is the key to success.
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Affiliation(s)
- Senthilkumar Sankararaman
- Division of Pediatric Gastroenterology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital / Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Teresa Schindler
- Division of Pediatric Pulmonology, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital, Cleveland, OH, USA
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Mailhot G, Denis MH, Beauchamp-Parent C, Jomphe V. Nutritional management of people living with cystic fibrosis throughout life and disease continuum: Changing times, new challenges. J Hum Nutr Diet 2023; 36:1675-1691. [PMID: 37515397 DOI: 10.1111/jhn.13214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
Cystic fibrosis (CF) is a genetic disease caused by mutations in the gene encoding for the ion channel cystic fibrosis transmembrane conductance regulator (CFTR). The management of CF disease has evolved in recent decades from treating downstream disease manifestations affecting the airways, the lungs and the gastrointestinal system to addressing the CFTR gene defect. The advent of CFTR modulators, which correct the functionality of the defective CFTR, contributes to reshaping the landscape of CF demographics, prognosis and therapies, including nutritional management. A spectrum of clinical manifestations is emerging within the same patient population where undernutrition and nutritional deficiencies coexist with excessive weight gain and metabolic derangements. Such contrasting presentations challenge current practices, require adjustments to traditional approaches, and involve more individualised interventions. This narrative review examines the current state of knowledge on the nutritional management of people living with cystic fibrosis from early life to adulthood in the era of CFTR modulation.
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Affiliation(s)
- Geneviève Mailhot
- Department of Nutrition, Faculty of Medicine, Montreal, QC, Canada
- CHU Sainte-Justine Research Center, Montreal, QC, Canada
| | | | | | - Valérie Jomphe
- Lung Transplant Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
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16
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Ramsey LB, Prows CA, Tang Girdwood S, Van Driest S. Current Practices in Pharmacogenomics. Pediatr Clin North Am 2023; 70:995-1011. [PMID: 37704356 PMCID: PMC10865383 DOI: 10.1016/j.pcl.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Pharmacogenomics, where genomic information is used to tailor medication management, is a strategy to maximize drug efficacy and minimize toxicity. Although pediatric evidence is less robust than for adults, medications influenced by pharmacogenomics are prescribed to children and adolescents. Evidence-based guidelines and drug label annotations are available from the Clinical Pharmacogenetics Implementation Consortium (CPIC) and the Pharmacogenomics Knowledgebase (PharmGKB). Some pediatric health care facilities use pharmacogenomics to provide dosing recommendations to pediatricians. Herein, we use a case-based approach to illustrate the use of pharmacogenomic data in pediatric clinical care and provide resources for finding and using pharmacogenomic guidelines.
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Affiliation(s)
- Laura B Ramsey
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA; Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA.
| | - Cynthia A Prows
- Division of Human Genetics, Department of Pediatrics and Center for Professional Excellence, Patient Services, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 6018, Cincinnati, OH 45229, USA
| | - Sonya Tang Girdwood
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA; Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA; Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 9016, Cincinnati, OH 45529, USA
| | - Sara Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, 2200 Children's Way, 8232 DOT, Nashville, TN 37205, USA
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Yule A, Sills D, Smith S, Spiller R, Smyth AR. Thinking outside the box: a review of gastrointestinal symptoms and complications in cystic fibrosis. Expert Rev Respir Med 2023; 17:547-561. [PMID: 37345513 DOI: 10.1080/17476348.2023.2228194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/19/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Gastrointestinal (GI)-related symptoms, complications, and comorbidities in cystic fibrosis (CF) are common and research to reduce their burden is a priority for the CF community. To enable future research, this review aimed to summarize the range of GI symptoms, complications and comorbidities seen in CF, the underlying pathophysiology, and treatments. AREAS COVERED This was a rapid systematic review undertaken using the recommendations from the Cochrane Rapid Reviews Methods Group. We searched databases including PubMed, Embase, Medline and the Cochrane database and identified those studies reporting GI-related symptoms, complications, or comorbidities in CF or their treatment. Our searches identified 2,930 studies and a total 119 studies met our inclusion criteria. Where a prevalence could be determined, GI symptoms were reported in 33.7% of study participants. The range of symptoms reported was broad and the highest median prevalence included flatulence (43.5%), bloating and abdominal distension (36%), and fatty stool (36%). Meconium ileus was reported in 12% and distal intestinal obstruction syndrome in 8.5. EXPERT OPINION GI-related symptoms, complications, and comorbidities in CF are common. More consistent characterization and recording of these symptoms in clinical studies may help achieve the priority of reducing the burden of GI disease in CF.
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Affiliation(s)
- Alexander Yule
- Academic Unit of Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
| | - Darren Sills
- Nutrition and Dietetics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sherie Smith
- Academic Unit of Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robin Spiller
- NIHR Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
- Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alan R Smyth
- Academic Unit of Lifespan & Population Health, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Biomedical Research Centre, Nottingham University Hospital NHS Trust and University of Nottingham, Nottingham, UK
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Harris JK, Wagner BD, Robertson CE, Stevens MJ, Lingard C, Borowitz D, Leung DH, Heltshe SL, Ramsey BW, Zemanick ET. Upper airway microbiota development in infants with cystic fibrosis diagnosed by newborn screen. J Cyst Fibros 2023; 22:644-651. [PMID: 37137746 PMCID: PMC10524365 DOI: 10.1016/j.jcf.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/03/2023] [Accepted: 04/21/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Changes in upper airway microbiota may impact early disease manifestations in infants with cystic fibrosis (CF). To investigate early airway microbiota, the microbiota present in the oropharynx of CF infants over the first year of life was assessed along with the relationships between microbiota and growth, antibiotic use and other clinical variables. METHODS Oropharyngeal (OP) swabs were collected longitudinally between 1 and 12 months of age from infants diagnosed with CF by newborn screen and enrolled in the Baby Observational and Nutrition Study (BONUS). DNA extraction was performed after enzymatic digestion of OP swabs. Total bacterial load was determined by qPCR and community composition assessed using 16S rRNA gene analysis (V1/V2 region). Changes in diversity with age were evaluated using mixed models with cubic B-splines. Associations between clinical variables and bacterial taxa were determined using a canonical correlation analysis. RESULTS 1,052 OP swabs collected from 205 infants with CF were analyzed. Most infants (77%) received at least one course of antibiotics during the study and 131 OP swabs were collected while the infant was prescribed an antibiotic. Alpha diversity increased with age and was only marginally impacted by antibiotic use. Community composition was most highly correlated with age and was only moderately correlated with antibiotic exposure, feeding method and weight z-scores. Relative abundance of Streptococcus decreased while Neisseria and other taxa increased over the first year. CONCLUSIONS Age was more influential on the oropharyngeal microbiota of infants with CF than clinical variables including antibiotics in the first year of life.
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Affiliation(s)
- J Kirk Harris
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 13123 E. 16th Ave, B-395, Aurora, CO 80045, USA.
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Charles E Robertson
- Department of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mark J Stevens
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 13123 E. 16th Ave, B-395, Aurora, CO 80045, USA
| | - Conor Lingard
- Spartanburg Regional Healthcare Systems, Spartanburg, SC, USA
| | - Drucy Borowitz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Sonya L Heltshe
- Cystic Fibrosis Foundation Therapeutic Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Bonnie W Ramsey
- Cystic Fibrosis Foundation Therapeutic Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Edith T Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, 13123 E. 16th Ave, B-395, Aurora, CO 80045, USA
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Ramsey B, Bush A. Cystic Fibrosis: From Tragedy to Triumph. Am J Respir Crit Care Med 2023; 208:9-11. [PMID: 37167625 PMCID: PMC10870854 DOI: 10.1164/rccm.202305-0785ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Affiliation(s)
- Bonnie Ramsey
- Department of Pediatrics University of Washington School of Medicine Seattle, Washington
| | - Andrew Bush
- Imperial Centre for Paediatrics and Child Health Imperial College London, United Kingdom and Department of Paediatric Respiratory Medicine Royal Brompton Hospital London, United Kingdom
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Abstract
Importance Cystic fibrosis, a genetic disorder defined by variants in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, affects more than 30 000 individuals in the US and approximately 89 000 worldwide. Absent or decreased function of the CFTR protein is associated with multiorgan dysfunction and shortened life expectancy. Observations CFTR is an anion channel in the apical membrane of epithelial cells. Loss of function leads to obstructed exocrine glands. Of people with cystic fibrosis in the US, approximately 85.5% have the gene variant F508del. Manifestations of cystic fibrosis in patients with the F508del gene variant begin in infancy with steatorrhea, poor weight gain, and respiratory symptoms (coughing, wheezing). As people with cystic fibrosis age, chronic respiratory bacterial infections cause loss of lung function and bronchiectasis. With the availability of universal newborn screening in multiple countries including the US, many people with cystic fibrosis are asymptomatic at diagnosis. With multidisciplinary care teams that included dietitians, respiratory therapists, and social workers, treatment of cystic fibrosis can slow disease progression. Median survival has improved from 36.3 years (95% CI, 35.1-37.9) in 2006 to 53.1 years (95% CI, 51.6-54.7) in 2021. Pulmonary therapies for patients with cystic fibrosis consist of mucolytics (eg, dornase alfa), anti-inflammatories (eg, azithromycin), and antibiotics (such as tobramycin delivered by a nebulizer). Four small molecular therapies, termed CFTR modulators, that facilitate CFTR production and/or function have received regulatory approval. Examples are ivacaftor and elexacaftor-tezacaftor-ivacaftor. For example, in patients with 1 F508del variant, the combination of ivacaftor, tezacaftor, and elexacaftor improved lung function from -0.2% in the placebo group to 13.6% (difference, 13.8%; 95% CI, 12.1%-15.4%) and decreased the annualized estimated rate of pulmonary exacerbations from 0.98 to 0.37 (rate ratio, 0.37; 95% CI, 0.25-0.55). Improved respiratory function and symptoms have lasted up to 144 weeks in postapproval observational studies. An additional 177 variants are eligible for treatment with the elexacaftor-tezacaftor-ivacaftor combination. Conclusion Cystic fibrosis affects approximately 89 000 people worldwide and is associated with a spectrum of disease related to exocrine dysfunction, including chronic respiratory bacterial infections and reduced life expectancy. First-line pulmonary therapies consist of mucolytics, anti-inflammatories, and antibiotics, and approximately 90% of people with cystic fibrosis who are 2 years or older may benefit from a combination of ivacaftor, tezacaftor, and elexacaftor.
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Affiliation(s)
- Thida Ong
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle
| | - Bonnie W Ramsey
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle
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Granados A, Chan CL, Moheet A, Vigers T, Arbeláez AM, Larson Ode K. The impact of elexacaftor/tezacaftor/ivacaftor on body composition in a small cohort of youth with cystic fibrosis. Pediatr Pulmonol 2023; 58:1805-1811. [PMID: 36929859 DOI: 10.1002/ppul.26388] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/06/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND The effects of elexacaftor-tezacaftor-ivacaftor (ETI) on body composition in people with CF (pwCF) are unknown. METHODS Dual-energy X-ray absorptiometry fat-free mass and fat mass adjusted for height (FMI) as well as oral glucose tolerance test derived measures of insulin secretion and sensitivity were compared before and after ETI initiation in eight pwCF. RESULTS Patients median age: 22 years interquartile range (IQR: 16-28), 87.5% male, median time on ETI:11 months. Weight z-score increased from -0.52 to 0.18 (p = 0.014); FMI increased from 4.12 to 6.29 (p = 0.014). Insulin secretion (C pep iAUC/Gluc iAUC) increased from 8.71 to 14.21 (p = 0.021), insulin resistance (HOMA2 IR) increased from 0.73 to 1.25 (p = 0.014) and insulin sensitivity decreased (Matsuda) 8.88 to 5.58 (p = 0.036). CONCLUSIONS ETI resulted in increased weight and fat mass. BMI and muscle mass did not change. Both insulin secretion and insulin resistance increased. Longer-term metabolic consequences of ETI need further investigation.
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Affiliation(s)
- Andrea Granados
- Department of Pediatrics, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Christine L Chan
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amir Moheet
- Division of Diabetes, Department of Medicine, Endocrinology and Metabolism, University of Minnesota, Minneapolis, Minnesota, USA
| | - Timothy Vigers
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ana María Arbeláez
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Katie Larson Ode
- Department of Pediatrics, University of Iowa Stead Family Children's hospital, Iowa City, Iowa, USA
- Fraternal Order of Eagles Diabetes Research Center, University of Iowa, Iowa City, Iowa, USA
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22
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Zheng Y, Mostamand S. Nutrition in children with exocrine pancreatic insufficiency. Front Pediatr 2023; 11:943649. [PMID: 37215591 PMCID: PMC10196508 DOI: 10.3389/fped.2023.943649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is a condition defined as pancreatic loss of exocrine function, including decreased digestive enzymes and bicarbonate secretion, which leads to maldigestion and malabsorption of nutrients. It is a common complication in many pancreatic disorders. If left undiagnosed, EPI can cause poor digestion of food, chronic diarrhea, severe malnutrition and related complications. Nutritional status and fat-soluble vitamins should be carefully assessed and monitored in patients with EPI. Early diagnosis of EPI is clinically important for appropriate nutritional support and initiating pancreatic enzyme replacement therapy (PERT) which could significantly improve patient outcomes. The evaluation of nutritional status and related unique management in children with EPI will be discussed in this review.
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Affiliation(s)
- Yuhua Zheng
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Shikib Mostamand
- Gastroenterology, Hepatology, and Nutrition, Stanford Children’s Health & Stanford University School of Medicine, Palo Alto, CA, United States
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23
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Ong T, Bell S, Britto MT, Gamel B, McNamara S, Ramsey B, Barton KS. Transforming the nutrition care model for infants with cystic fibrosis: A qualitative study of clinicians' perspectives. Pediatr Pulmonol 2023; 58:1380-1390. [PMID: 36695543 PMCID: PMC10121817 DOI: 10.1002/ppul.26330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/17/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
Clinician perspectives may inform health service strategies to meet optimal nutrition needs for infants with cystic fibrosis (CF). We conducted a qualitative study with CF-specialized dietitians (registered dietitians [RDs]) and physicians between July to December 2020 to characterize the current state of infant nutrition care delivery and organize input into a conceptual model to inform CF care program strategies. Among 42 participants, 36 completed survey responses and 6 completed interviews; 93% were RDs. Three global themes emerged in the current care model: nutrition management, family centered connections, and collaborative care delivery. Within nutrition management, clinicians emphasized providing education, setting goals, and maintaining adequate follow-up with families. Under family centered connections, clinicians expressed the need to foster relationships with families and link families to resources for assistance to social stressors such as food insecurity. Collaborative care delivery for clinicians interviewed was defined by sharing expertise from across the interdisciplinary team. Based on the timing of this study, clinicians reported compelling examples for various modes of telehealth and home weight monitoring to facilitate and support these domains of nutrition care, including potential advantages for education, supporting family needs, and communication. We integrate these themes to propose a conceptual model to organize complementary in-person and telehealth activities and enhance quality infant CF nutrition care delivery. Future implementation can refine this model through testing of practical telehealth interventions to optimize nutrition outcomes for infants with CF.
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Affiliation(s)
- Thida Ong
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Hospital, Seattle, Washington, USA
| | - Sarah Bell
- Seattle Children’s Hospital, Seattle, Washington, USA
| | - Maria T. Britto
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Breck Gamel
- Children’s Health Pediatric Cystic Fibrosis Center Dallas, UTSW, Dallas, Texas, USA
| | | | - Bonnie Ramsey
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children’s Hospital, Seattle, Washington, USA
| | - Krysta S. Barton
- Seattle Children’s Research Institute, Biostatistics Epidemiology and Analytics for Research (BEAR) Core, Seattle, Washington, USA
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Psoter KJ, Dickinson KM, Riekert KA, Collaco JM. Early life growth trajectories in cystic fibrosis are associated with lung function at age six. J Cyst Fibros 2023; 22:395-401. [PMID: 36858852 PMCID: PMC10257762 DOI: 10.1016/j.jcf.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/11/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Higher growth percentiles are associated with more favorable lung function in cystic fibrosis (CF), prompting the creation of CF Foundation (CFF) nutritional guidelines. OBJECTIVES To describe early childhood growth trajectories within CF, to determine if growth trajectories are associated with differences in lung function at age six, and to identify factors that differ between trajectory groups. METHODS Retrospective cohort study of children diagnosed with CF and born 2000-2011 using the US CFF Patient Registry. Annualized growth parameters prior to age six were included in group-based trajectory modeling to identify unique early life growth trajectories. FEV1 percent predicted (FEV1pp) at age six was compared between trajectory groups using linear regression. Factors associated with group membership were identified using multinomial logistic regression. RESULTS 6,809 children met inclusion criteria. Six discrete growth trajectories were identified, including three groups that began with growth parameters >50th percentile, termed: "always high", "gradual decliner", "rapid decliner", and three which began with growth parameters <50th percentile, termed: "rapid riser", "gradual riser", "always low". FEV1pp at age six was highest for the Always High trajectory. The Always Low trajectory was nearly 10% lower than the Always High trajectory. Sex, ethnicity, newborn screening and pancreatic function were associated with trajectory class membership. CONCLUSIONS Distinct early life growth trajectories were identified within CF. Trajectories that met CFF nutritional guideline recommendations were associated with higher FEV1pp at age six. CF care teams should continue to partner with families to encourage interventions to support optimal growth to improve lung function in CF.
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Affiliation(s)
- Kevin J Psoter
- Division of General Pediatrics, Department of Pediatrics, Johns Hopkins University, Baltimore, MD.
| | - Kimberly M Dickinson
- Department of Pediatrics, Pulmonary Section, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Joseph M Collaco
- Division of Pediatric Pulmonology, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
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25
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Salinas DB, Ginsburg DK, Wee CP, Saeed MM, Brewington JJ. Gradual increase in sweat chloride concentration is associated with a higher risk of CRMS/CFSPID to CF reclassification. Pediatr Pulmonol 2023; 58:1074-1084. [PMID: 36582049 DOI: 10.1002/ppul.26296] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 12/10/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Universal implementation of cystic fibrosis (CF) newborn screening (NBS) has led to the diagnostic dilemma of infants with CF screen-positive, inconclusive diagnosis (CFSPID), with limited guidance regarding prognosis and standardized care. Rates of reclassification from CFSPID to CF vary and risk factors for reclassification are not well established. We investigated whether clinical characteristics are associated with the risk of reclassification from CFSPID to a CF diagnosis. METHODS Children with a positive CF NBS were recruited from two sites in California. Retrospective, longitudinal, and cross-sectional data were collected. A subset of subjects had nasal epithelial cells collected for CF transmembrane conductance regulator (CFTR) functional assessment. Multivariate logistic regression was used to assess the risk of reclassification. RESULTS A total of 112 children completed the study (CF = 53, CFSPID = 59). Phenotypic characteristics between groups showed differences in pancreatic insufficiency prevalence, immunoreactive trypsinogen (IRT) levels, and Pseudomonas aeruginosa (PSA) colonization. Spirometry measures were not different between groups. Nasal epithelial cells from 10 subjects showed 7%-30% of wild-type (WT)-CFTR (wtCFTR) function in those who reclassified and 27%-67% of wtCFTR function in those who retained the CFSPID designation. Modeling revealed that increasing sweat chloride concentration (sw[Cl- ]) and PSA colonization were independent risk factors for reclassification to CF. CONCLUSION Increasing sw[Cl- ] and a history of PSA colonization are associated with the risk of reclassification from CFSPID to CF in a population with high IRT and two CFTR variants. A close follow-up to monitor phenotypic changes remains critical in this population. The role of CFTR functional assays in this population requires further exploration.
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Affiliation(s)
- Danieli B Salinas
- Department of Pediatrics, Division of Pediatric Pulmonology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Daniella K Ginsburg
- Department of Pediatrics, Division of Pediatric Pulmonology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Choo Phei Wee
- Department of Population and Public Health Sciences, Keck School of Medicine, Southern California Clinical and Translational Science Institute (SC-CTSI), University of Southern California, Los Angeles, California, USA
| | - Muhammed M Saeed
- Division of Pediatric Pulmonology, Kaiser Permanente Los Angles Medical Center, Los Angeles, California, USA
| | - John J Brewington
- Department of Pediatrics, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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26
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Zobell JT, Moss J, Creelman J, Christensen R, Jensen B, Stewart J, Ameel K, Asfour F. Implementation of a comprehensive pharmacy-driven immunization care process model in a pediatric cystic fibrosis clinic. Pediatr Pulmonol 2023; 58:1145-1151. [PMID: 36600452 DOI: 10.1002/ppul.26306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/30/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Members of an integrated pharmacy team (pharmacists and pharmacy technicians) have roles that have been identified in the literature as part of the multi-disciplinary cystic fibrosis (CF) care team. One role that has not specifically addressed is the administration of routine and recommended immunizations to people with CF (PwCF). According to care guidelines, PwCF of all ages should be provided all age-appropriate and recommended immunizations. Pharmacists and pharmacy technicians can administer immunizations per state laws. The Primary Children's CF Center decided to implement a comprehensive pharmacy-driven immunization care process model to impact immunization rates. METHODS A 24-month retrospective analysis was conducted with pediatric (≤18 years) PwCF at the Primary Children's CF Center. The primary outcome measures were the percentage (%) of PwCF who received PPSV23, and/or HPV, and/or meningococcal conjugate vaccine (MCV) immunizations 1-year post-care process model implementation (October 1, 2021, to September 30, 2022) as compared to baseline values. The secondary outcome measures are the total number of immunizations, the number of each immunization provided, and the financial impact of pharmacy-driven immunization care process model 1-year post-implementation. RESULTS During the 1-year post-care process model implementation (October 1, 2021, to September 30, 2022), a total of 523 immunizations were provided to 243 pediatric PwCF. The most frequent immunizations provided were PPSV23 (160/523, 31%) and Coronavirus Disease 2019 (COVID-19) (154/523, 29%). The baseline percentages of eligible PwCF of PPSV23, HPV, and MCV were 27% (58/217), 43% (32/74), and 24% (8/34), respectively. The 1-year post-implementation percentages of PPSV23, HPV, and MCV were 99% (217/218, p < 0.00001), 91% (67/74, p < 0.00001), and 97% (33/34, p < 0.00001), respectively. For COVID-19 immunizations, 56% of eligible PwCF (181/321) have received their first dose. Of these 181 PwCF, 70% (126/181) have received at least one dose of their primary series or booster during the 1-year post-implementation period. The rate of those PwCF who have received at least one dose of a COVID-19 immunization from the age of 6 months to 4 years, 5-11 years, and 12-18 years, was 37% (30/82), 60% (78/129), and 66% (73/110), respectively. For the financial impact generated during the 1-year immunization care process model post-implementation period, 404 non-VFC immunizations were given for an estimated profit of $11,930. CONCLUSIONS The implementation of a pharmacy-driven immunization care process model is a way for integrated pharmacy teams to evolve with the CF center care model and have a role expansion in the care provided to PwCF.
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Affiliation(s)
- Jeffery T Zobell
- Department of Pharmacy, Primary Children's Cystic Fibrosis Center, Salt Lake City, Utah, USA.,Department of Pharmacy, Intermountain Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Justin Moss
- Department of Pharmacy, Primary Children's Cystic Fibrosis Center, Salt Lake City, Utah, USA.,Department of Pharmacy, Intermountain Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jenna Creelman
- Department of Pharmacy, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Rilee Christensen
- Department of Pharmacy, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Bevan Jensen
- Department of Pharmacy, Intermountain Primary Children's Outpatient Pharmacy, Salt Lake City, Utah, USA
| | - Jennifer Stewart
- Department of Pharmacy, Primary Children's Cystic Fibrosis Center, Salt Lake City, Utah, USA.,Department of Pediatric Pulmonology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kristen Ameel
- Department of Pharmacy, Primary Children's Cystic Fibrosis Center, Salt Lake City, Utah, USA.,Department of Pediatric Pulmonology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Fadi Asfour
- Department of Pharmacy, Primary Children's Cystic Fibrosis Center, Salt Lake City, Utah, USA.,Department of Pediatric Pulmonology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Mariotti Zani E, Grandinetti R, Cunico D, Torelli L, Fainardi V, Pisi G, Esposito S. Nutritional Care in Children with Cystic Fibrosis. Nutrients 2023; 15:nu15030479. [PMID: 36771186 PMCID: PMC9921127 DOI: 10.3390/nu15030479] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/18/2023] Open
Abstract
Patients with cystic fibrosis (CF) are prone to malnutrition and growth failure, mostly due to malabsorption caused by the derangement in the chloride transport across epithelial surfaces. Thus, optimal nutritional care and support should be an integral part of the management of the disease, with the aim of ameliorating clinical outcomes and life expectancy. In this report, we analyzed the nutrition support across the different ages, in patients with CF, with a focus on the relationships with growth, nutritional status, disease outcomes and the use of the CF transmembrane conductance regulator (CFTR) modulators. The nutrition support goal in CF care should begin as early as possible after diagnosis and include the achievement of an optimal nutritional status to support the growth stages and puberty development in children, that will further support the maintenance of an optimal nutritional status in adult life. The cornerstone of nutrition in patients with CF is a high calorie, high-fat diet, in conjunction with a better control of malabsorption due to pancreatic enzyme replacement therapy, and attention to the adequate supplementation of fat-soluble vitamins. When the oral caloric intake is not enough for reaching the anthropometric nutritional goals, supplemental enteral feeding should be initiated to improve growth and the nutritional status. In the last decade, the therapeutic possibilities towards CF have grown in a consistent way. The positive effects of CFTR modulators on nutritional status mainly consist in the improvement in weight gain and BMI, both in children and adults, and in an amelioration in terms of the pulmonary function and reduction of exacerbations. Several challenges need to be overcome with the development of new drugs, to transform CF from a fatal disease to a treatable chronic disease with specialized multidisciplinary care.
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Affiliation(s)
- Elena Mariotti Zani
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Roberto Grandinetti
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Daniela Cunico
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Lisa Torelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giovanna Pisi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-903524
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Pilot study to determine whether reduced-dose photon-counting detector chest computed tomography can reliably display Brody II score imaging findings for children with cystic fibrosis at radiation doses that approximate radiographs. Pediatr Radiol 2023; 53:1049-1056. [PMID: 36596868 DOI: 10.1007/s00247-022-05574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/23/2022] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND The Brody II score uses chest CT to guide therapeutic changes in children with cystic fibrosis; however, patients and providers are often reticent to undergo chest CT given concerns about radiation. OBJECTIVE We sought to determine the ability of a reduced-dose photon-counting detector (PCD) chest CT protocol to reproducibly display pulmonary disease severity using the Brody II score for children with cystic fibrosis (CF) scanned at radiation doses similar to those of a chest radiograph. MATERIALS AND METHODS Pediatric patients with CF underwent non-contrast reduced-dose chest PCD-CT. Volumetric inspiratory and expiratory scans were obtained without sedation or anesthesia. Three pediatric radiologists with Certificates of Added Qualification scored each scan on an ordinal scale and assigned a Brody II score to grade bronchiectasis, peribronchial thickening, parenchymal opacity, air trapping and mucus plugging. We report image-quality metrics using descriptive statistics. To calculate inter-rater agreement for Brody II scoring, we used the Krippendorff alpha and intraclass correlation coefficient (ICC). RESULTS Fifteen children with CF underwent reduced-dose PCD chest CT in both inspiration and expiration (mean age 8.9 years, range, 2.5-17.5 years; 4 girls). Mean volumetric CT dose index (CTDIvol) was 0.07 ± 0.03 mGy per scan. Mean effective dose was 0.12 ± 0.04 mSv for the total examination. All three readers graded spatial resolution and noise as interpretable on lung windows. The average Brody II score was 12.5 (range 4-19), with moderate inter-reader reliability (ICC of 0.61 [95% CI=0.27, 0.84]). Inter-rater reliability was moderate to substantial for bronchiectasis (0.52), peribronchial thickening (0.55), presence of opacity (0.62) and air trapping (0.70) and poor for mucus plugging (0.09). CONCLUSION Reduced-dose PCD-CT permits diagnostic image quality and reproducible identification of Brody II scoring imaging findings at radiation doses similar to those for chest radiography.
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Ritivoiu ME, Drăgoi CM, Matei D, Stan IV, Nicolae AC, Craiu M, Dumitrescu IB, Ciolpan AA. Current and Future Therapeutic Approaches of Exocrine Pancreatic Insufficiency in Children with Cystic Fibrosis in the Era of Personalized Medicine. Pharmaceutics 2023; 15:pharmaceutics15010162. [PMID: 36678791 PMCID: PMC9862205 DOI: 10.3390/pharmaceutics15010162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/17/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023] Open
Abstract
This review presents current updates of pancreatic enzyme replacement therapy in children with cystic fibrosis based on literature published in the last decade and some special considerations regarding pancreatic enzyme replacement therapy in the era of new therapies, such as cystic fibrosis transmembrane conductance regulator modulator therapies. Few articles evaluate the efficacy of pancreatic enzyme replacement therapy in the pediatric population, and most studies also included children and adults with cystic fibrosis. Approximately 85% of cystic fibrosis patients have exocrine pancreatic insufficiency and need pancreatic enzyme replacement therapy. Fecal elastase is the most commonly used diagnostic test for exocrine pancreatic insufficiency, although this value can fluctuate over time. While it is used as a diagnostic test, it cannot be used for monitoring the effectiveness of pancreatic enzyme replacement therapy and for adjusting doses. Pancreatic enzyme replacement therapy, the actual treatment for exocrine pancreatic insufficiency, is essential in children with cystic fibrosis to prevent malabsorption and malnutrition and needs to be urgently initiated. This therapy presents many considerations for physicians, patients, and their families, including types and timing of administration, dose monitoring, and therapy failures. Based on clinical trials, pancreatic enzyme replacement therapy is considered effective and well-tolerated in children with cystic fibrosis. An important key point in cystic fibrosis treatment is the recent hypothesis that cystic fibrosis transmembrane conductance regulator modulators could improve pancreatic function, further studies being essential. Pancreatic enzyme replacement therapy is addressed a complication of the disease (exocrine pancreatic insufficiency), while modulators target the defective cystic fibrosis transmembrane conductance regulator protein. Exocrine pancreatic insufficiency in cystic fibrosis remains an active area of research in this era of cystic fibrosis transmembrane conductance regulator modulator therapies. This new therapy could represent an example of personalized medicine in cystic fibrosis patients, with each class of modulators being addressed to patients with specific genetic mutations.
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Affiliation(s)
- Mirela-Elena Ritivoiu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
| | - Cristina Manuela Drăgoi
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
- Correspondence: (C.M.D.); (A.C.N.)
| | - Dumitru Matei
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
| | - Iustina Violeta Stan
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
| | - Alina Crenguţa Nicolae
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
- Correspondence: (C.M.D.); (A.C.N.)
| | - Mihai Craiu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
| | - Ion-Bogdan Dumitrescu
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
| | - Alina Angelica Ciolpan
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
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30
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An Ethical Argument for Health Insurance Coverage of Paternal Prenatal Genetic Testing. Obstet Gynecol 2023; 141:11-14. [PMID: 36701605 DOI: 10.1097/aog.0000000000005018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 09/22/2022] [Indexed: 12/23/2022]
Abstract
Despite evidence-based recommendations from the American College of Obstetricians and Gynecologists and the American College of Medical Genetics to offer prenatal genetic carrier screening for reproductive partners, partner carrier screening or genetic testing is inconsistently covered by pregnant patients' health insurance plans. Health policies that exclude reproductive partners from insurance coverage for prenatal carrier screening or genetic testing contradict multiple ethical principles and can even contribute to adverse maternal-child health outcomes. Incomplete or missing information regarding partner carrier status can lead to costly, invasive, and potentially risky interventions for the pregnant patient that can be avoided by a simple and less expensive blood test in the reproductive partner. Lack of information regarding carrier status also harms the neonate by obviating an opportunity for early detection and treatment of potential medical complications. Insurance policies that exclude coverage for paternal genetic testing perpetuate the disproportionate burdens of pregnancy care and risk shouldered by pregnant people. To rectify these ethical dilemmas, partner carrier screening and genetic testing should be considered and covered as routine components of obstetric health care that are covered by health insurance.
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Bhat JI, Tramboo ZM, Shah TH, Charoo BA, Qazi IA. Enhancing respiratory disease diagnosis by bronchoalveolar lavage in Kashmir: an audit of findings. Arch Dis Child 2022; 107:1079-1082. [PMID: 35948407 DOI: 10.1136/archdischild-2022-323823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/30/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study bronchoalveolar lavage (BAL) findings in various respiratory diseases in children in Kashmir India. DESIGN Prospective observational study. SETTING Paediatric department of the tertiary care hospital. PATIENTS Children of both genders from 1 month to 17 years of age INTERVENTION: All studied patients underwent flexible bronchoscopy and BAL. OUTCOME MEASURE To observe the BAL findings in various respiratory diseases in the studied population. RESULTS A total of 283 patients underwent BAL procedure. The positive BAL report was received in 131 (46%) patients. Out of these, 55 (42%) patients had positive BAL culture/ microscopy for different bacterial (50) and fungal species (Candida spp (3), Mucormycosis (1) and Aspergillus (1)). MTB was isolated in 25 (19%) patients. Twenty-three (17.5%) patients had bronchoalveolar lavage fluid (BALF) positive for pulmonary hydatidosis. Foamy macrophages were seen in 13 patients, significant eosinophilia in nine patients and hemosiderin-laden macrophages were seen in three patients. CONCLUSION We found BALF a very useful sample for the evaluation of many infective and non-infective respiratory diseases in our region, which otherwise lacks high end diagnostics. 46% of our patients had some abnormalities in the BAL specimen. It provided us with valuable information regarding organism profile and drug sensitivity in case of lung infection. BALF analysis was also found useful in the diagnosis of some non-infective pulmonary disorders like acute eosinophilic pneumonia, aspiration syndromes and bronchial asthma.
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Affiliation(s)
- Javeed Iqbal Bhat
- Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Zubair M Tramboo
- Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Tajamul Hussain Shah
- Department of Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Iqbal Ahmad Qazi
- Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
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Moni SS, Al Basheer A. Molecular targets for cystic fibrosis and therapeutic potential of monoclonal antibodies. Saudi Pharm J 2022; 30:1736-1747. [PMID: 36601503 PMCID: PMC9805982 DOI: 10.1016/j.jsps.2022.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/01/2022] [Indexed: 12/24/2022] Open
Abstract
Cystic fibrosis (CF) is a genetic disease that affects the exocrine glands and is caused by cystic fibrosis transmembrane conductance regulator gene (CFTR) mutations. Lung disease is the leading cause of morbidity in patients. Target-specific treatment of CF has been achieved using monoclonal antibodies (mAbs). The purpose of this article is to discuss the possibility of treating CF with mAbs through their significant target specificity. We searched electronic databases in Web of Science, PubMed, EMBASE, Scopus, and Google Scholar from 1984 to 2021. We discussed the critical role of targeted therapy in cystic fibrosis, as it will be more effective at suppressing the molecular networks. After conducting a critical review of the available literature, we concluded that it is critical to understand the fundamental molecular mechanisms underlying CF prior to incorporating biologics into the therapy regimen. Omalizumab, Mepolizumab, Benralizumab, Dupilumab and KB001-A have been successfully screened for asthma-complicated CF, and their efficacies have been well reported. Despite the availability of effective targeted biologics, treating CF has remained a difficult task, particularly when it comes to reduction of secondary inflammatory mediators. This review emphasizes the overall views on CF, the immunological mechanism of CF, and the prospective therapeutic use of mAbs as potential targeted biologics for enhancing the overall status of human health.
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Huang L, Lai HJ, Antos N, Rock MJ, Asfour F, Howenstine M, Gaffin JM, Farrell PM. Defining and identifying early-onset lung disease in cystic fibrosis with cumulative clinical characteristics. Pediatr Pulmonol 2022; 57:2363-2373. [PMID: 35712759 PMCID: PMC9489630 DOI: 10.1002/ppul.26040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/24/2022] [Accepted: 06/08/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Because of the heterogeneity in cystic fibrosis (CF) lung disease among young children, a clinical method to identify early-onset lung disease is needed. OBJECTIVE To develop a CF early-onset lung disease (CFELD) scoring system by utilizing prospectively collected longitudinal data on manifestations in the first 3 years of life. DESIGN We studied 145 infants born during 2012-2017, diagnosed through newborn screening by age 3 months, and followed to 36 months of age. Cough severity, pulmonary exacerbations (PEx), respiratory cultures, and hospitalizations were collected at each CF center visit (every 1-2 months in infancy and quarterly thereafter). These data were used to construct the CFELD system and to classify lung disease into five categories: asymptomatic, minimal, mild, moderate, and severe. RESULTS The most frequent manifestation of CF early lung disease was MD-reported PEx episodes, PEx hospitalizations, and positive Pseudomonas aeruginosa cultures. Parent-reported cough severity was correlated with the number of respiratory hospitalizations (r = 0.48, p < 0.0001). The distribution of CFELD categories was 10% asymptomatic, 17% minimal, 29% mild, 33% moderate, and 12% severe. The moderate and severe categories occurred threefold higher in pancreatic insufficient (PI, 49%) versus sufficient subjects (16%), p < 0.0001. In addition to PI, gastrointestinal and nutrition-related hospitalizations, plasma cytokines interleukin (IL)-6 and IL-10, duration of CFTR modulator therapy, and type of health insurance were significant predictors of CFELD scores. CONCLUSION The CFELD scoring system is novel, allows systematic evaluation of lung disease prognosis early, and may aid in therapeutic decision-making particularly in the initiation of CFTR modulator therapy.
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Affiliation(s)
- Leslie Huang
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - HuiChuan J. Lai
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Department of Nutritional Sciences, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Nicholas Antos
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael J. Rock
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, USA
| | - Fadi Asfour
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | | | - Jonathan M. Gaffin
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Philip M. Farrell
- Department of Pediatrics, University of Wisconsin–Madison, Madison, Wisconsin, USA
- Department of Population Health Sciences, University of Wisconsin–Madison, Madison, Wisconsin, USA
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Pulvirenti G, Sortino V, Manti S, Parisi GF, Papale M, Giallongo A, Leonardi S. Pathogenesis, diagnosis, dietary management, and prevention of gastrointestinal disorders in the paediatric population. Ital J Pediatr 2022; 48:172. [PMID: 36089576 PMCID: PMC9465927 DOI: 10.1186/s13052-022-01366-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 09/04/2022] [Indexed: 11/13/2022] Open
Abstract
Nutrition has a central role in child growth with long-term effects, and nutrition management in gastrointestinal disorders has great importance for child health and disease outcomes. Breast milk is the first choice for infant nutrition. When it is not available, special milk formulas are adopted in specific conditions, as a medical treatment. Moving from the strong guidelines, recommendations and the new possibilities of special diet treatment, this review will analyse the current diet treatment in different gastrointestinal disorders, including food allergy, cystic fibrosis, inflammatory bowel diseases, short-bowel syndrome, gastroesophageal reflux, and eosinophilic esophagitis. The review also aimed at understanding the role of diet and its effects on these diseases. The growth monitoring can prevent malnutrition and improve disease outcomes, particularly in children, and an appropriate dietary management targeted to specific disorders is the best therapeutic choice alone or in combination with pharmacological therapy.
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Freeman AJ, Huang R, Heltshe SL, Gelfond D, Leung DH, Ramsey BR, Borowitz D, Sathe M. Association between stool consistency and clinical variables among infants with cystic fibrosis: Findings from the BONUS study. J Cyst Fibros 2022; 21:830-836. [PMID: 35585010 PMCID: PMC10056424 DOI: 10.1016/j.jcf.2022.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/04/2022] [Accepted: 05/06/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Concerns related to stool consistency are common in the first year of life among children with cystic fibrosis (CF). However, normal stool patterns for infants with CF have not been described. METHODS Secondary analysis was completed from the previously described BONUS cohort which followed 231 infants with CF through the first 12 months of life. Pain, stool category, stool frequency, feeding type, PERT dose, acid suppression medication, antibiotics usage, stool softener usage and fecal calprotectin were described at 3, 6, and 12 months. Repeated measure ANOVA was used to test the difference in mean stool number. Generalized linear mixed models were used to investigate the relationship between stool characteristics and various factors. RESULTS The frequency of constipation was stable throughout the first year of life (10-13%) while watery stool significantly decreased from 21.3% at 3 months to 5.8% at 12 months (p=<0.001). The number of stools at months 6 (mean=2.40) and 12 (mean=2.50) are significantly lower than in month 3 (mean=2.83), p<0.025. Exclusive breast feeding was associated with an increased risk for constipation (OR=2.64 [1.60-4.37], p = 0.002) while exclusive formula feeding and acid suppression was associated with decreased risk for constipation (OR=0.40 [0.26-0.61], p=<0.0001 and OR=0.59 [0.39-0.89], p = 0.01 respectively). Pain was not significantly associated with stool consistency. CONCLUSION Stool frequency and consistency evolves in infant with CF in a fashion similar to that reported in non-CF infants over the first year. Constipation was not associated with pain and was less common among infants receiving acid suppression or exclusively formula feeding.
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Affiliation(s)
- A Jay Freeman
- Associate Professor, Division Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, GA, USA.
| | - Rong Huang
- Lead Biostatistician, Research Administration, Children's Medical Center Dallas, Dallas, TX, USA
| | - Sonya L Heltshe
- Associate Professor, Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA and Division of Pulmonary Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Daniel Gelfond
- WNY Pediatric Gastroenterology and Volunteer Faculty, University of Buffalo School of Medicine, Buffalo, NY, USA
| | - Daniel H Leung
- Associate Professor, Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Bonnie R Ramsey
- Vice Chair and Endowed Professor, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Drucy Borowitz
- Emeritus Clinical Professor of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Meghana Sathe
- Associate Professor, Division Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Texas Southwestern and Children's Health, Dallas, TX, USA
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Sankararaman S, Hendrix SJ, Schindler T. Update on the management of vitamins and minerals in cystic fibrosis. Nutr Clin Pract 2022; 37:1074-1087. [PMID: 35997322 PMCID: PMC9544449 DOI: 10.1002/ncp.10899] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/27/2022] [Accepted: 07/16/2022] [Indexed: 11/10/2022] Open
Abstract
Advancements in respiratory and nutrition management have significantly improved the survival of patients with cystic fibrosis (CF). With the availability of several nutrition interventions such as oral/enteral nutrition supplements, enteric‐coated pancreatic enzymes, and water‐miscible CF‐specific vitamin supplements, frank vitamin deficiencies—with the exception of vitamin D—are rarely encountered in current clinical practice. Whereas they were previously considered as micronutrients, our current understanding of fat‐soluble vitamins and minerals as antioxidants, immunomodulators, and disease biomarkers has been evolving. The impact of highly effective modulators on the micronutrient status of patients with CF remains elusive. This narrative review focuses on the updates on the management of fat‐soluble vitamins and other micronutrients in CF in the current era and identifies the gaps in our knowledge.
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Affiliation(s)
- Senthilkumar Sankararaman
- Department of Pediatrics, Division of Pediatric Gastroenterology, UH Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sara J Hendrix
- Department of Nutrition Services, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Terri Schindler
- Department of Pediatrics, Division of Pediatric Pulmonology, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
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Lai HJ, Song J, Lu Q, Murali SG, Gajapathy M, Wilk BM, Brown DM, Worthey EA, Farrell PM. Genetic factors help explain the variable responses of young children with cystic fibrosis to vitamin D supplements. Clin Nutr ESPEN 2022; 51:367-376. [DOI: 10.1016/j.clnesp.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/11/2022] [Accepted: 07/28/2022] [Indexed: 10/15/2022]
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Green HD, Jones AM. Managing Pulmonary Infection in Adults With Cystic Fibrosis: Adult Cystic Fibrosis Series. Chest 2022; 162:66-75. [PMID: 35167860 DOI: 10.1016/j.chest.2022.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 02/04/2022] [Accepted: 02/04/2022] [Indexed: 12/17/2022] Open
Abstract
Cystic fibrosis (CF) is characterized by chronic airway infection and progressive respiratory decline. Historically, a narrow spectrum of bacterial pathogens was believed to comprise the bulk of respiratory infections in CF, with Haemophilus influenzae and Staphylococcus aureus dominating childhood infections, and Pseudomonas aeruginosa or, less commonly, a member of the Burkholderia cepacia complex becoming the dominant infecting organism in adulthood. Today, the landscape is changing for airway infection in CF. The prevalence of "less typical" gram-negative bacterial infections are rising due to a number of factors: the CF population is aging; new therapies are being introduced; antibiotic usage is increasing; diagnostic tests are evolving; and taxonomic changes are being made as new bacterial species are being discovered. Less is known about the clinical relevance and evidence for treatment strategies for many of the other lower prevalence organisms that are encountered in CF. The aim of this article was to discuss the current evidence and recommended strategies for treating airway infection in CF, focusing on bacterial infections.
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Affiliation(s)
- Heather D Green
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, England
| | - Andrew M Jones
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, England; Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, England.
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Sontag MK, Miller JI, McKasson S, Gaviglio A, Martiniano SL, West R, Vazquez M, Ren CL, Farrell PM, McColley SA, Kellar-Guenther Y. Newborn Screening for Cystic Fibrosis: A Qualitative Study of Successes and Challenges from Universal Screening in the United States. Int J Neonatal Screen 2022; 8:ijns8030038. [PMID: 35892468 PMCID: PMC9326751 DOI: 10.3390/ijns8030038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
Cystic fibrosis (CF) newborn screening (NBS) was universally adopted in 2009 in the United States. Variations in NBS practices between states may impact the timing of diagnosis and intervention. Quantitative metrics can provide insight into NBS programs (NBSP), but the nuances cannot be elucidated without additional feedback from programs. This study was designed to determine facilitators and barriers to timely diagnosis and intervention following NBS for CF. The median age at the first CF event for infants with CF within each state was used to define early and late states (n = 15 per group); multiple CF centers were invited in states with more than two CF centers. Thirty states were eligible, and 61 NBSP and CF centers were invited to participate in structured interviews to determine facilitators and barriers. Once saturation of themes was reached, no other interviews were conducted. Forty-five interviews were conducted (n = 16 early CF center, n = 12 late CF center, n = 11 early NBSP, and n = 6 late NBSP). Most interviewees reported good communication between CF centers and NBSP. Communication between primary care providers (PCPs) and families was identified as a challenge, leading to delays in referral and subsequent diagnosis. The misperception of low clinical risk in infants from racial and ethnic minority groups was a barrier to early diagnostic evaluation for all groups. NBSP and CF centers have strong relationships. Early diagnosis may be facilitated through more engagement with PCPs. Quality improvement initiatives should focus on continuing strong partnerships between CF centers and NBS programs, improving education, communication strategies, and partnerships with PCPs, and improving CF NBS timeliness and accuracy.
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Affiliation(s)
- Marci K. Sontag
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
- Colorado School of Public Health, University of Colorado Anschutz Medical Center, Aurora, CO 80045, USA
- Correspondence: ; Tel.: +1-303-867-1315
| | - Joshua I. Miller
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
| | - Sarah McKasson
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
| | - Amy Gaviglio
- Connetics Consulting, Minneapolis, MN 55417, USA;
| | - Stacey L. Martiniano
- Children’s Hospital Colorado, Aurora, CO 80045, USA;
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Rhonda West
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
| | - Marisol Vazquez
- Ann & Robert H. Lurie Children’s Hospital, Chicago, IL 60611, USA; (M.V.); (S.A.M.)
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Clement L. Ren
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
- Division of Pulmonary and Sleep Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Philip M. Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI 53705, USA;
| | - Susanna A. McColley
- Ann & Robert H. Lurie Children’s Hospital, Chicago, IL 60611, USA; (M.V.); (S.A.M.)
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Yvonne Kellar-Guenther
- Center for Public Health Innovation at CI International, Littleton, CO 80120, USA; (J.I.M.); (S.M.); (R.W.); (Y.K.-G.)
- Colorado School of Public Health, University of Colorado Anschutz Medical Center, Aurora, CO 80045, USA
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de Aquino CSB, Rodrigues JC, da Silva-Filho LVRF. Routine spirometry in cystic fibrosis patients: impact on pulmonary exacerbation diagnosis and FEV1 decline. J Bras Pneumol 2022; 48:e20210237. [PMID: 35674545 PMCID: PMC9262437 DOI: 10.36416/1806-3756/e20210237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 02/26/2022] [Indexed: 06/15/2023] Open
Abstract
OBJECTIVE Pulmonary disease in cystic fibrosis (CF) is characterised by recurrent episodes of pulmonary exacerbations (PExs), with acute and long-term declines in lung function (FEV1). The study sought to determine whether routine spirometry increases the frequency of PEx diagnosis, resulting in benefits to long-term pulmonary function. METHODS CF patients in the 5- to 18-year age bracket were followed for 1 year, during which they underwent spirometry before every medical visit. The main variables were the frequency of PEx diagnosis and use of antibiotics; the use of spirometry as a criterion for PEx diagnosis (a decline ≥ 10% in baseline FEV1); and median percent predicted FEV1 over time. The data were compared with those for the previous 24-month period, when spirometry was performed electively every 6 months. RESULTS The study included 80 CF patients. PExs were diagnosed in 27.5% of the visits, with a mean frequency of 1.44 PExs per patient/year in 2014 vs. 0.88 PExs per patient/year in 2012 (p = 0.0001) and 1.15 PExs per patient/year in 2013 (p = 0.05). FEV1 was used as a diagnostic feature in 83.5% of PExs. In 21.9% of PExs, the decision to initiate antibiotics was solely based on an acute decline in FEV1. The median percent predicted FEV1 during the follow-up year was 85.7%, being 78.5% in 2013 and 76.8% in 2012 (p > 0.05). The median percent predicted FEV1 remained above 80% during the two years after the study. CONCLUSIONS Routine spirometry is associated with higher rates of diagnosis and treatment of PExs, possibly impacting long-term pulmonary function.
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Affiliation(s)
| | - Joaquim Carlos Rodrigues
- . Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Luiz Vicente Ribeiro Ferreira da Silva-Filho
- . Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
- . Centro de Pesquisa Experimental, Instituto de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo (SP) Brasil
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Marpole R, Wilson AC. Benefits of reviewing pancreatic function in children with cystic fibrosis. Pediatr Pulmonol 2022; 57:1537-1539. [PMID: 35258175 PMCID: PMC9313857 DOI: 10.1002/ppul.25884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/27/2022] [Accepted: 03/05/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Rachael Marpole
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Division of Paediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia, Crawley, Western Australia, Australia.,Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Andrew C Wilson
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Division of Paediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia, Crawley, Western Australia, Australia.,Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Nedlands, Western Australia, Australia
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Dunn A, Jung D, Bollinger LL, Krams M, Smith BP, Gobburu JVS. Accelerating the Availability of Medications to Pediatric Patients by Optimizing the Use of Extrapolation of Efficacy. Ther Innov Regul Sci 2022; 56:873-882. [PMID: 35471560 DOI: 10.1007/s43441-022-00411-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/07/2022] [Indexed: 11/25/2022]
Abstract
Improving pediatric therapeutic development is a mission of universal importance among health authorities, pharmaceutical companies, academic institutions, and healthcare professionals. Following the passage of legislation in the United States and Europe, we witnessed the most significant advancement yet in pediatric data generation, resulting in added pediatric use information to almost 700 product labels. Tools to accelerate generation of data for the pediatric population are available for use today, and when utilized in accordance with current practices and laws, these tools could increase the amount and timeliness of pediatric information available for clinicians and patients. If we utilize the current laws that allow regulators to incentivize and require evidence generation, apply extrapolation, and utilize modeling and simulation, as well as including adolescents in the pivotal studies alongside adults as appropriate, two strategic goals could be achieved by 2030: (1) reduce the time to pediatric approval by 50%, and (2) renew pediatric labeling information for 15 priority pediatric drugs without patent and/or exclusivity.
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Affiliation(s)
- Allison Dunn
- Center for Translational Medicine, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD, 21201, USA
| | - Dawoon Jung
- Center for Translational Medicine, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD, 21201, USA
| | | | - Michael Krams
- Janssen Research & Development, Spring House, PA, USA
| | - Brian P Smith
- Early Development Analytics, Novartis Institutes of Biomedical Research, Cambridge, MA, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD, 21201, USA.
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Langfelder-Schwind E, Raraigh KS, Parad RB. Genetic counseling access for parents of newborns who screen positive for cystic fibrosis: Consensus guidelines. Pediatr Pulmonol 2022; 57:894-902. [PMID: 34964558 DOI: 10.1002/ppul.25806] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION A risk associated with cystic fibrosis newborn screening (CFNBS) is parental misunderstanding of genetic information generated by the over 6600 positive screens reported annually in the United States. CFNBS algorithms incorporating DNA analysis can generate genetic information that requires clinical interpretation and has significance for the newborn, parents, and other relatives. Engagement between CF care centers and trained genetic counseling providers, such as licensed and/or certified genetic counselors (GCs), is variable and limited in providing information to CFNBS positive (CFNBS+) families. METHODS Using a modified Delphi process, a workgroup of CFNBS experts developed recommendation statements for engagement of genetic counseling services in CF care centers where CFNBS + diagnostic evaluations are performed. Statements were assessed over three rounds of surveys, one face-to-face meeting, and through public feedback. RESULTS Seventeen statements achieved >80% consensus (range: 82%-100%). The workgroup affirmed prior CFF policy statements recommending genetic counseling for parents of infants with CFNBS+. The remaining statements addressed infrastructure and logistics of genetic counseling services, including defining appropriate training for genetic counseling providers and counseling content, establishing a path to equal access to genetic counseling providers across CF care centers, and setting a standard for client-centered CFNBS genetic counseling that is respectful of diverse patient needs and autonomy. CONCLUSIONS Implementation of client-centered genetic counseling for CFNBS+ families in CF care centers by providers with expertise in both CF and genetic counseling will require efforts to further define core concepts, enhance the education of providers, and develop opportunities for access via telemedicine.
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Affiliation(s)
- Elinor Langfelder-Schwind
- Department of Pulmonary, Critical Care, and Sleep Medicine, The Cystic Fibrosis Center, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Karen S Raraigh
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Richard B Parad
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Maryland, USA
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Zysman-Colman Z, Munsar Z, Sheikh S, Rubenstein RC, Kelly A. Infant Body Mass Index or Weight-for-Length and Risk of Undernutrition in Childhood Among Children with Cystic Fibrosis. J Pediatr 2022; 243:116-121.e3. [PMID: 34871592 DOI: 10.1016/j.jpeds.2021.11.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare performance of weight-for-length and body mass index as estimators of undernutrition in children with cystic fibrosis (CF). STUDY DESIGN We analyzed pediatric anthropometric data from the Cystic Fibrosis Foundation Patient Registry. Undernutrition was defined by weight-for-length z score (WFLZ) or body mass index z score (BMIZ) ≤-1 (15th-percentile). Group 1, reference group, consisted of subjects with both BMIZ and WFLZ >-1; group 2: BMIZ ≤-1 and WFLZ >-1; group 3: BMIZ >-1 and WFLZ ≤-1; and group 4: BMIZ and WFLZ ≤-1. Group differences in length-for-age-Z across ages 2-24 months were tested using generalized estimating equations. The association of group at age 2 months with BMIZ <-1 at age 6 years was tested using logistic regression adjusted for demographic and disease characteristics. RESULTS Overall, 163 482 anthropometric measurements were available from 12 640 individuals, of whom 16.8% were discordant for undernutrition status at age 2 months. Discordance (1.5%-10%) was less common with increasing age. Length-for-age-Z was lower in group 2 than group 1 and group 3 between birth and 24 months (P < .05). Odds of WFLZ-defined undernourished at 2 months were lower for shorter individuals (OR 1.5, CI 1.4-1.6, P < .001). Undernutrition risk at age 6 years was greater for group 2 vs group 3 (OR 1.9 vs 1.0, P < .001). CONCLUSIONS Infants with cystic fibrosis classified as undernourished by BMIZ, but not WFLZ, had greater risk of undernourished status later in childhood. Infants with low BMIZ but normal WFLZ tended to be shorter, suggesting BMIZ may better capture undernourished status than WFLZ in shorter infants.
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Affiliation(s)
- Zofia Zysman-Colman
- Division of Respiratory Medicine, Centre Hospitalier Universitaire Sainte Justine, Montreal, Quebec, Canada
| | - Zoya Munsar
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Saba Sheikh
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ronald C Rubenstein
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, MO
| | - Andrea Kelly
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA.
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45
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Lai HJ, Chin LH, Murali S, Bach T, Sander D, Farrell PM. Vitamins A, D, E status as related to supplementation and lung disease markers in young children with cystic fibrosis. Pediatr Pulmonol 2022; 57:935-944. [PMID: 35018747 PMCID: PMC8930603 DOI: 10.1002/ppul.25825] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/22/2021] [Accepted: 01/08/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND The variable response to fat-soluble vitamin supplementation in young children with cystic fibrosis (CF), and factors contributing to this variability, remain under-investigated. OBJECTIVE To determine if recommended supplement doses normalize serum vitamins A (retinol), D (25-hydroxy-vitamin D, 25OHD), and E (α-tocopherol), and identify factors predictive of achieving sufficiency, in children with CF in the first 3 years of life. DESIGN We studied 144 infants born during 2012-2017 and diagnosed with CF through newborn screening. Serum retinol, 25OHD, α-tocopherol and plasma cytokines interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor (TNF)-α were measured in early infancy and yearly thereafter. Vitamin supplement intakes and respiratory microbiology were assessed every 1-2 months in infancy and quarterly thereafter. RESULTS The prevalence of vitamin D insufficiency (<30 ng/ml) at all ages combined was significantly higher (22%) compared to vitamin A (<200 ng/ml, 3%) and vitamin E (<5 µg/ml, 5%). All children were vitamin A sufficient by age 2 years. Vitamin E insufficiency was rare. Only 42% were early responders of vitamin D and 17% remain insufficient despite high supplement intakes. IL-6 was positively correlated, while IL-8, IL-10, and TNF-α were negatively correlated, with retinol and 25OHD. Multiple regression analysis revealed that supplement dose, season, α-tocopherol, pancreatic insufficiency, respiratory infections and IL-10 were significant predictors of 25OHD. CONCLUSION Diagnosis through newborn screening coupled with supplementation normalized serum retinol and α-tocopherol in almost all infants with CF by age 3 years. However, response to vitamin D supplements in young children with CF occurred later and variably despite early and sustained supplementation.
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Affiliation(s)
- HuiChuan J Lai
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Lyanne H Chin
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sangita Murali
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Taiya Bach
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Danielle Sander
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Philip M Farrell
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
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46
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Freswick PN, Reid EK, Mascarenhas MR. Pancreatic Enzyme Replacement Therapy in Cystic Fibrosis. Nutrients 2022; 14:nu14071341. [PMID: 35405954 PMCID: PMC9003370 DOI: 10.3390/nu14071341] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
While typically considered a pulmonary disease, cystic fibrosis patients develop significant nutritional complications and comorbidities, especially those who are pancreatic insufficient. Clinicians must have a high suspicion for cystic fibrosis among patients with clinical symptoms of pancreatic insufficiency, and pancreatic enzymatic replacement therapy (PERT) must be urgently initiated. PERT presents a myriad of considerations for patients and their supporting dieticians and clinicians, including types of administration, therapy failures, and complications.
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Affiliation(s)
- Peter N. Freswick
- Helen DeVos Children’s Hospital, Grand Rapids, MI 49503, USA
- Correspondence:
| | - Elizabeth K. Reid
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (E.K.R.); (M.R.M.)
| | - Maria R. Mascarenhas
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (E.K.R.); (M.R.M.)
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47
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Hamilton JL, Snuggerud AE, Meihls SM, Toledo H, Stewart J. Quality improvement and rapid PDSA cycles to maintain routine surveillance of pulmonary pathogens during the COVID-19 pandemic in a pediatric cystic fibrosis clinic. J Pediatr Nurs 2022; 63:131-135. [PMID: 34953664 PMCID: PMC8607846 DOI: 10.1016/j.pedn.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 11/05/2021] [Accepted: 11/06/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The COVID-19 pandemic necessitated immediate transition from in person to telehealth encounters; novel nursing practices were needed to ensure that children with cystic fibrosis (CF) receive care that approximates evidence-based guidelines. LOCAL PROBLEM The aim was to ensure that as many children as possible received routine surveillance of pulmonary pathogens by a CF culture sputum culture during a pandemic. METHODS Multiple Plan-Do-Study-Act (PDSA) cycles were utilized to implement practice change over four months. INTERVENTIONS Cultures were obtained via curbside appointment with a registered nurse (RN) or at the patients' home with mailed equipment. RESULTS 133 cultures obtained: 50.37% (67) by RN collection curbside and 49.62% (66) by self/caregiver at home. 120 culture swabs or sterile cups were mailed; 55% (66) were returned. Cost of mailing equipment was $760.16. CONCLUSION Nursing utilization of PDSA cycles developed novel processes that ensured guideline-based care during the initial months of the pandemic.
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Affiliation(s)
- Jennifer L Hamilton
- School of Medicine, Department of Pediatrics, University of Utah Health Sciences, 81 Mario Capecchi Dr, Salt Lake City, UT 84112, United States of America; College of Nursing, University of Utah Health Sciences, 10 2000 E, Salt Lake City, UT 84112, United States of America.
| | - Anne E Snuggerud
- School of Medicine, Department of Pediatrics, University of Utah Health Sciences, 81 Mario Capecchi Dr, Salt Lake City, UT 84112, United States of America.
| | - Suzanne M Meihls
- School of Medicine, Department of Pediatrics, University of Utah Health Sciences, 81 Mario Capecchi Dr, Salt Lake City, UT 84112, United States of America.
| | - Heidi Toledo
- School of Medicine, Department of Pediatrics, University of Utah Health Sciences, 81 Mario Capecchi Dr, Salt Lake City, UT 84112, United States of America.
| | - Jennifer Stewart
- School of Medicine, Department of Pediatrics, University of Utah Health Sciences, 81 Mario Capecchi Dr, Salt Lake City, UT 84112, United States of America.
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Abstract
Rationale Cystic fibrosis (CF) centers transitioned to telemedicine during the spring 2020 peak of the coronavirus disease (COVID-19) pandemic. Objectives We hypothesized that people with CF (pwCF) with more severe disease would be more likely to be seen in-person. Methods We used paired t tests to compare within-subject changes in body mass index (BMI) and percentage predicted forced expiratory volume in one second (FEV1) and calculated relative risk (RR) to compare pulmonary exacerbations (PEx) between pwCF enrolled in the CF Foundation Patient Registry with at least one in-person clinic visit after March 15 in both 2019 and 2020. Results Overall, the proportion of clinical encounters that were in-person clinic visits decreased from 91% in 2019 to a low of 9% in April 2020. Among pwCF seen after March 15 in both 2019 and 2020, the mean (95% confidence interval [CI]) FEV1 percentage predicted was 1.3% (0.1–2.4) predicted higher in 2020 for children 6 to <12 years of age, and 7.5% (7.1–7.9) predicted higher in 2020 among pwCF ⩾12 years of age eligible for the highly effective CF transmembrane conductance regulator modulator, elexacaftor-tezacaftor-ivacaftor (ETI). There was no difference in FEV1 percentage predicted for pwCF ⩾12 years of age who were not eligible for ETI. Similarly, the mean (95% CI) BMI was 2.4 (2.0–2.8) percentile higher in 2020 for children 6 to <12 years of age and 5.2 (4.8–5.7) percentile higher in 2020 among children 12 to <18 years of age eligible for ETI. Mean (95% CI) BMI was 1.2 (1.2–1.3) (kg/m2) higher for pwCF ⩾18 years of age eligible for ETI, and 0.2 (0.1–0.3) (kg/m2) higher for pwCF ⩾18 years of age not eligible for ETI. The proportion of in-person clinic visits where any PEx was present was lower in 2020 compared with 2019, 25% compared with 38%, RR 0.82 (0.79–0.86). Conclusions The care of pwCF was substantially changed during the spring 2020 peak of the COVID-19 pandemic. Among pwCF seen in-person in both 2019 and 2020 after the spring peak of the COVID-19 pandemic, lung function and BMI were higher in 2020 for children 6 to <12 years of age and pwCF eligible for ETI.
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49
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Shape JM, Sala MA. Nutrition management in adults with cystic fibrosis. Nutr Clin Pract 2022; 37:256-264. [PMID: 35118712 DOI: 10.1002/ncp.10842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 11/12/2022] Open
Abstract
Cystic fibrosis (CF) is a lethal, monogenic, autosomal recessive disease with manifestations in multiple organ systems, including the lungs and gastrointestinal tract, that impact adequate nutrition. This review discusses important aspects of nutrition in adults with CF with a focus on exocrine pancreatic insufficiency, CF-related diabetes, and gastrointestinal motility, as well as how advanced lung disease, CF transmembrane conductance regulator modulators, and aging impact nutrition in CF.
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Affiliation(s)
- Jessica M Shape
- Clinical Nutrition Services, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Marc A Sala
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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50
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Lahiri T, Sullivan JS. Recent advances in the early treatment of cystic fibrosis: Bridging the gap to highly effective modulator therapy. Pediatr Pulmonol 2022; 57 Suppl 1:S60-S74. [PMID: 34473419 DOI: 10.1002/ppul.25660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/22/2021] [Accepted: 09/01/2021] [Indexed: 11/08/2022]
Abstract
Highly effective modulator therapy (HEMT) for cystic fibrosis (CF) has been touted as one of the greatest advances to date in CF care. As these therapies are now available for many older children and adults with CF, marked improvement of their nutritional status, pulmonary and gastrointestinal symptoms has been observed. However, most infants and younger children are not current candidates for HEMT due to age and/or cystic fibrosis transmembrane conductance regulator (CFTR) mutation. For these young children, it is essential to provide rigorous monitoring and care to avoid potential disease sequelae while awaiting HEMT availability. The following article highlights recent advances in the care of infants and young children with CF with regard to surveillance and treatment of nutritional, pulmonary, and gastrointestinal disorders. Recent clinical trials in this population are also reviewed.
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Affiliation(s)
- Thomas Lahiri
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Jillian S Sullivan
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
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