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Caverly LJ, Riquelme SA, Hisert KB. The Impact of Highly Effective Modulator Therapy on Cystic Fibrosis Microbiology and Inflammation. Clin Chest Med 2022; 43:647-665. [PMID: 36344072 PMCID: PMC10224747 DOI: 10.1016/j.ccm.2022.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Highly effective cystic fibrosis (CF) transmembrane conductance regulator (CFTR) modulator therapy (HEMT) corrects the underlying molecular defect causing CF disease. HEMT decreases symptom burden and improves clinical metrics and quality of life for most people with CF (PwCF) and eligible cftr mutations. Improvements in measures of pulmonary health suggest that restoration of function of defective CFTR anion channels by HEMT not only enhances airway mucociliary clearance, but also reduces chronic pulmonary infection and inflammation. This article reviews the evidence for how HEMT influences the dynamic and interdependent processes of infection and inflammation in the CF airway, and what questions remain unanswered.
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Affiliation(s)
- Lindsay J Caverly
- Department of Pediatrics, University of Michigan Medical School, L2221 UH South, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5212, USA
| | - Sebastián A Riquelme
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, Columbia University Medical Center, 650West 168th Street, New York, NY 10032, USA
| | - Katherine B Hisert
- Department of Medicine, National Jewish Health, Smith A550, 1400 Jackson Street, Denver, CO 80205, USA.
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2
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Zorzo C, Girón RM, Hernández S, Gómez-Punter RM, Caballero P. Association Between Evolution of Mucus Plugging, Parenchymal Alterations and Air Trapping on Computed Tomography and Risk of Exacerbations in Adults With Cystic Fibrosis. Arch Bronconeumol 2022; 58:575-577. [PMID: 35312590 DOI: 10.1016/j.arbres.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/02/2022]
Affiliation(s)
- Cristina Zorzo
- Department of Radiology, Hospital Universitario La Princesa, Calle Diego de León, 52, 28006 Madrid, Spain; Universidad Autónoma de Madrid, Spain.
| | - Rosa María Girón
- Department of Respiratory Medicine, Hospital Universitario La Princesa, Calle Diego de León, 52, 28006 Madrid, Spain; Universidad Autónoma de Madrid, Spain
| | - Susana Hernández
- Department of Radiology, Hospital Universitario La Princesa, Calle Diego de León, 52, 28006 Madrid, Spain; Universidad Autónoma de Madrid, Spain
| | - Rosa Mar Gómez-Punter
- Department of Respiratory Medicine, Hospital Universitario La Princesa, Calle Diego de León, 52, 28006 Madrid, Spain; Universidad Autónoma de Madrid, Spain
| | - Paloma Caballero
- Department of Radiology, Hospital Universitario La Princesa, Calle Diego de León, 52, 28006 Madrid, Spain; Universidad Autónoma de Madrid, Spain
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Ciet P, Bertolo S, Ros M, Casciaro R, Cipolli M, Colagrande S, Costa S, Galici V, Gramegna A, Lanza C, Lucca F, Macconi L, Majo F, Paciaroni A, Parisi GF, Rizzo F, Salamone I, Santangelo T, Scudeller L, Saba L, Tomà P, Morana G. State-of-the-art review of lung imaging in cystic fibrosis with recommendations for pulmonologists and radiologists from the "iMAging managEment of cySTic fibROsis" (MAESTRO) consortium. Eur Respir Rev 2022; 31:31/163/210173. [PMID: 35321929 DOI: 10.1183/16000617.0173-2021] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/20/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Imaging represents an important noninvasive means to assess cystic fibrosis (CF) lung disease, which remains the main cause of morbidity and mortality in CF patients. While the development of new imaging techniques has revolutionised clinical practice, advances have posed diagnostic and monitoring challenges. The authors aim to summarise these challenges and make evidence-based recommendations regarding imaging assessment for both clinicians and radiologists. STUDY DESIGN A committee of 21 experts in CF from the 10 largest specialist centres in Italy was convened, including a radiologist and a pulmonologist from each centre, with the overall aim of developing clear and actionable recommendations for lung imaging in CF. An a priori threshold of at least 80% of the votes was required for acceptance of each statement of recommendation. RESULTS After a systematic review of the relevant literature, the committee convened to evaluate 167 articles. Following five RAND conferences, consensus statements were developed by an executive subcommittee. The entire consensus committee voted and approved 28 main statements. CONCLUSIONS There is a need for international guidelines regarding the appropriate timing and selection of imaging modality for patients with CF lung disease; timing and selection depends upon the clinical scenario, the patient's age, lung function and type of treatment. Despite its ubiquity, the use of the chest radiograph remains controversial. Both computed tomography and magnetic resonance imaging should be routinely used to monitor CF lung disease. Future studies should focus on imaging protocol harmonisation both for computed tomography and for magnetic resonance imaging. The introduction of artificial intelligence imaging analysis may further revolutionise clinical practice by providing fast and reliable quantitative outcomes to assess disease status. To date, there is no evidence supporting the use of lung ultrasound to monitor CF lung disease.
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Affiliation(s)
- Pierluigi Ciet
- Radiology and Nuclear Medicine Dept, Erasmus MC, Rotterdam, The Netherlands .,Pediatric Pulmonology and Allergology Dept, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands.,Depts of Radiology and Medical Science, University of Cagliari, Cagliari, Italy
| | - Silvia Bertolo
- Radiology Dept, Ca'Foncello S. Maria Hospital, Treviso, Italy
| | - Mirco Ros
- Dept of Pediatrics, Ca'Foncello S. Maria Hospital, Treviso, Italy
| | - Rosaria Casciaro
- Dept of Pediatrics, IRCCS Institute "Giannina Gaslini", Cystic Fibrosis Centre, Genoa, Italy
| | - Marco Cipolli
- Regional Reference Cystic Fibrosis center, University hospital of Verona, Verona, Italy
| | - Stefano Colagrande
- Dept of Experimental and Clinical Biomedical Sciences, Radiodiagnostic Unit n. 2, University of Florence- Careggi Hospital, Florence, Italy
| | - Stefano Costa
- Dept of Pediatrics, Gaetano Martino Hospital, Messina, Italy
| | - Valeria Galici
- Cystic Fibrosis Centre, Dept of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Andrea Gramegna
- Respiratory Disease and Adult Cystic Fibrosis Centre, Internal Medicine Dept, IRCCS Ca' Granda, Milan, Italy.,Dept of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Cecilia Lanza
- Radiology Dept, University Hospital Ospedali Riuniti, Ancona, Italy
| | - Francesca Lucca
- Regional Reference Cystic Fibrosis center, University hospital of Verona, Verona, Italy
| | - Letizia Macconi
- Radiology Dept, Tuscany Reference Cystic Fibrosis Centre, Meyer Children's Hospital, Florence, Italy
| | - Fabio Majo
- Dept of Pediatrics, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | | | - Giuseppe Fabio Parisi
- Pediatric Pulmonology Unit, Dept of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesca Rizzo
- Radiology Dept, IRCCS Institute "Giannina Gaslini", Cystic Fibrosis Center, Genoa, Italy
| | | | - Teresa Santangelo
- Dept of Radiology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Luigia Scudeller
- Clinical Epidemiology, IRCCS Azienda Ospedaliera Universitaria di Bologna, Bologna, Italy
| | - Luca Saba
- Depts of Radiology and Medical Science, University of Cagliari, Cagliari, Italy
| | - Paolo Tomà
- Dept of Radiology, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
| | - Giovanni Morana
- Radiology Dept, Ca'Foncello S. Maria Hospital, Treviso, Italy
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4
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Patterns of Health Insurance Coverage and Lung Disease Progression in Adolescents and Young Adults with Cystic Fibrosis. Ann Am Thorac Soc 2021; 18:290-299. [PMID: 32885982 DOI: 10.1513/annalsats.201911-839oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Rationale: Health insurance coverage has been implicated as a socioeconomic factor affecting clinical outcomes in patients with cystic fibrosis (CF), but evidence for this is mixed and varies by age.Objectives: Focusing on adolescents and young adults with CF, we examined how multiyear patterns of health insurance coverage were associated with lung function decline and related outcomes.Methods: We used data from the 2000 to 2015 CF Foundation Patient Registry to classify patients in three cohorts (ages 12-17 yr, adolescents; 18-23 yr, transitioning to adulthood; and 24-29 yr, young adults) according to health insurance coverage, as follows: continuous private, continuous public, intermittent public, and coverage gaps. The primary outcome was the percentage predicted forced expiratory volume in 1 second (FEV1pp), which was modeled using mixed-effects regression. Additional outcomes included outpatient visits, hospital days for pulmonary exacerbation treatment, bacterial colonization, and body mass index. Outcomes were assessed over a 6-year period (e.g., ages 12-17 yr), whereas exposures were assessed over the prior 6 years (e.g., ages 6-11 yr).Results: The three cohorts included 3,365, 2,800, and 1,807 patients, respectively. The highest rate of FEV1pp decline was found in the middle cohort, with the annual decline being steeper among patients with continuous public (-3.1/yr; 95% confidence interval [CI], -3.3 to -2.8) or intermittent public (-2.4/yr; 95% CI, -2.6 to -2.2) coverage compared with patients with continuous private coverage (-2.1/yr; 95% CI, -2.2 to -2.0). These differences were not explained by differences in outpatient care utilization.Conclusions: During the transition to adulthood, use of public insurance was associated with accelerated lung function decline among patients with CF. The role of insurance as a causal factor in this decline or proxy for other socioeconomic characteristics should be explored in further studies.
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Perrem L, Stanojevic S, Shaw M, Jensen R, McDonald N, Isaac SM, Davis M, Clem C, Guido J, Jara S, France L, Solomon M, Grasemann H, Waters V, Sweezey N, Sanders DB, Davis SD, Ratjen F. Lung Clearance Index to Track Acute Respiratory Events in School-Age Children with Cystic Fibrosis. Am J Respir Crit Care Med 2021; 203:977-986. [PMID: 33030967 DOI: 10.1164/rccm.202006-2433oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Rationale: The lung clearance index (LCI) is responsive to acute respiratory events in preschool children with cystic fibrosis (CF), but its utility to identify and manage these events in school-age children with CF is not well defined.Objectives: To describe changes in LCI with acute respiratory events in school-age children with CF.Methods: In a multisite prospective observational study, the LCI and FEV1 were measured quarterly and during acute respiratory events. Linear regression was used to compare relative changes in LCI and FEV1% predicted at acute respiratory events. Logistic regression was used to compare the odds of a significant worsening in LCI and FEV1% predicted at acute respiratory events. Generalized estimating equation models were used to account for repeated events in the same subject.Measurements and Main Results: A total of 98 children with CF were followed for 2 years. There were 265 acute respiratory events. Relative to a stable baseline measure, LCI (+8.9%; 95% confidence interval, 6.5 to 11.3) and FEV1% predicted (-6.6%; 95% confidence interval, -8.3 to -5.0) worsened with acute respiratory events. A greater proportion of events had a worsening in LCI compared with a decline in FEV1% predicted (41.7% vs. 30.0%; P = 0.012); 53.9% of events were associated with worsening in LCI or FEV1. Neither LCI nor FEV1 recovered to baseline values at the next follow-up visit.Conclusions: In school-age children with CF, the LCI is a sensitive measure to assess lung function worsening with acute respiratory events and incomplete recovery at follow-up. In combination, the LCI and FEV1 capture a higher proportion of events with functional impairment.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada.,Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Children's Health Ireland, Dublin, Ireland
| | - Sanja Stanojevic
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Michelle Shaw
- Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Renee Jensen
- Division of Respiratory Medicine and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Nancy McDonald
- Division of Respiratory Medicine and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sarah M Isaac
- Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Miriam Davis
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Charles Clem
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Julia Guido
- Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sylvia Jara
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Lisa France
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Melinda Solomon
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Hartmut Grasemann
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Valerie Waters
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Neil Sweezey
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Don B Sanders
- Division of Pediatric Pulmonology, Riley Hospital for Children, Indianapolis, Indiana; and
| | - Stephanie D Davis
- Division of Pediatric Pulmonology, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Felix Ratjen
- Division of Respiratory Medicine and.,Department of Paediatrics and.,Translational Medicine Program, SickKids Research Institute, Toronto, Ontario, Canada
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Abstract
BACKGROUND Dornase alfa is currently used as a mucolytic to treat pulmonary disease (the major cause of morbidity and mortality) in cystic fibrosis. It reduces mucus viscosity in the lungs, promoting improved clearance of secretions. This is an update of a previously published review. OBJECTIVES To determine whether the use of dornase alfa in cystic fibrosis is associated with improved mortality and morbidity compared to placebo or other medications that improve airway clearance, and to identify any adverse events associated with its use. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstracts from conferences. Date of the most recent search of the Group's Cystic Fibrosis Register: 12 October 2020. Clinicaltrials.gov and the International Clinical Trials Registry Platform were also searched to identify unpublished or ongoing trials. Date of most recent search: 08 February 2021. SELECTION CRITERIA All randomised and quasi-randomised controlled trials comparing dornase alfa to placebo, standard therapy or other medications that improve airway clearance. DATA COLLECTION AND ANALYSIS Authors independently assessed trials against the inclusion criteria; two authors carried out analysis of methodological quality and data extraction. GRADE was used to assess the level of evidence. MAIN RESULTS The searches identified 74 trials, of which 19 (2565 participants) met our inclusion criteria. 15 trials compared dornase alfa to placebo or no dornase alfa (2447 participants); two compared daily dornase to hypertonic saline (32 participants); one compared daily dornase alfa to hypertonic saline and alternate day dornase alfa (48 participants); one compared dornase alfa to mannitol and the combination of both drugs (38 participants). Trial duration varied from six days to three years. Dornase alfa compared to placebo or no treatment Dornase alfa probably improved forced expiratory volume at one second (FEV1) at one month (four trials, 248 participants), three months (one trial, 320 participants; moderate-quality evidence), six months (one trial, 647 participants; high-quality evidence) and two years (one trial, 410 participants). Limited low-quality evidence showed treatment may make little or no difference in quality of life. Dornase alfa probably reduced the number of pulmonary exacerbations in trials of up to two years (moderate-quality evidence). One trial that examined the cost of care, including the cost of dornase alfa, found that the cost savings from dornase alfa offset 18% to 38% of the medication costs. Dornase alfa: daily versus alternate day One cross-over trial (43 children) found little or no difference between treatment regimens for lung function, quality of life or pulmonary exacerbations (low-quality evidence). Dornase alfa compared to other medications that improve airway clearance Results for these comparisons were mixed. One trial (43 children) showed dornase alfa may lead to a greater improvement in FEV1 compared to hypertonic saline (low-quality evidence), and one trial (23 participants) reported little or no differences in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol (low-quality evidence). One trial (23 participants) found dornase alfa may improve quality of life compared to dornase alfa plus mannitol (low-quality evidence); other comparisons found little or no difference in this outcome (low-quality evidence). No trials in any comparison reported any difference between groups in the number of pulmonary exacerbations (low-quality evidence). When all comparisons are assessed, dornase alfa did not cause significantly more adverse effects than other treatments, except voice alteration and rash. AUTHORS' CONCLUSIONS There is evidence to show that, compared with placebo, therapy with dornase alfa may improve lung function in people with cystic fibrosis in trials lasting from one month to two years. There was a decrease in pulmonary exacerbations in trials of six months or longer, probably due to treatment. Voice alteration and rash appear to be the only adverse events reported with increased frequency in randomised controlled trials. There is not enough evidence to firmly conclude if dornase alfa is superior to other hyperosmolar agents in improving lung function.
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Affiliation(s)
- Connie Yang
- Department of Pediatrics, Division of Respiratory Medicine, BC Children's Hospital, Vancouver, Canada
| | - Mark Montgomery
- Pediatrics and Child Health, Alberta Children's Hospital, Calgary, Canada
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7
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Abstract
BACKGROUND Inhalation of the enzyme dornase alfa reduces sputum viscosity and improves clinical outcomes of people with cystic fibrosis. This is an update of a previously published Cochrane Review. OBJECTIVES To determine whether the timing of dornase alfa inhalation (in relation to airway clearance techniques or morning versus evening inhalation) has an impact on objective and subjective measures of clinical efficacy in people with cystic fibrosis. SEARCH METHODS Relevant randomised and quasi-randomised controlled trials were identified from the Cochrane Cystic Fibrosis Trials Register, the Physiotherapy Evidence Database (PEDro), clinical trial registries and international cystic fibrosis conference proceedings. Date of the most recent search: 12 October 2020. SELECTION CRITERIA Any trial of dornase alfa in people with cystic fibrosis where timing of inhalation was the randomised element in the trial with either: inhalation before compared to after airway clearance techniques; or morning compared to evening inhalation. DATA COLLECTION AND ANALYSIS: Both authors independently selected trials, assessed risk of bias and extracted data with disagreements resolved by discussion. Relevant data were extracted and, where possible, meta-analysed. We assessed the quality of the evidence using GRADE. MAIN RESULTS We identified 115 trial reports representing 55 trials, of which five trials (providing data on 122 participants) met our inclusion criteria. All five trials used a cross-over design. Intervention periods ranged from two to eight weeks. Four trials (98 participants) compared dornase alfa inhalation before versus after airway clearance techniques. Inhalation after instead of before airway clearance did not significantly change forced expiratory volume at one second (very-low quality evidence). Similarly, forced vital capacity (low-quality evidence) and quality of life (very-low quality evidence) were not significantly affected; forced expiratory flow at 25% was significantly worse with dornase alfa inhalation after airway clearance, mean difference -0.17 litres (95% confidence interval -0.28 to -0.05), based on the pooled data from two small trials in children (7 to 19 years) with well-preserved lung function. All other secondary outcomes were statistically non-significant. In one trial (25 participants), morning versus evening inhalation had no impact on lung function or symptoms (low-quality evidence). AUTHORS' CONCLUSIONS The current evidence derived from a small number of participants does not indicate that inhalation of dornase alfa after airway clearance techniques is more or less effective than the traditional recommendation to inhale nebulised dornase alfa 30 minutes prior to airway clearance techniques, for most outcomes. For children with well-preserved lung function, inhalation before airway clearance may be more beneficial for small airway function than inhalation after. However, this result relied on a measure with high variability and trials with variable follow-up. In the absence of strong evidence to indicate that one timing regimen is better than another, the timing of dornase alfa inhalation can be largely based on pragmatic reasons or individual preference with respect to the time of airway clearance and time of day. Further research is warranted.
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Affiliation(s)
- Ruth Dentice
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Mark Elkins
- Sydney Medical School, University of Sydney, Sydney, Australia
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8
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Willmering MM, Roach DJ, Kramer EL, Walkup LL, Cleveland ZI, Woods JC. Sensitive structural and functional measurements and 1-year pulmonary outcomes in pediatric cystic fibrosis. J Cyst Fibros 2020; 20:533-539. [PMID: 33288474 DOI: 10.1016/j.jcf.2020.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/17/2020] [Accepted: 11/25/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Two functional measurements (multiple breath washout [MBW] and hyperpolarized 129Xe ventilation magnetic resonance imaging [129Xe MRI]) have been shown to be more sensitive to cystic fibrosis (CF) lung obstruction than traditional spirometry. However, functional techniques may be sensitive to different underlying structural abnormalities. The purpose of this study was to determine relationships between these functional markers, their pathophysiology, and 1-year clinical outcomes. METHODS Spirometry, MBW, 129Xe MRI, and ultrashort echo-time (UTE) MRI were obtained in a same-day assessment of 27 pediatric CF patients (ages 11.5±5.0) who had not begun CFTR modulator therapies. UTE MRI was scored for structural abnormalities and functional metrics obtained via spirometry, MBW and 129Xe MRI. 1-year outcomes (ΔFEV1 and pulmonary exacerbations), during which ≈50% initiated modulator therapy, were obtained from the electronic medical record. RESULTS MBW, 129Xe MRI, and UTE MRI detected clinically significant disease in more subjects (>78%) compared to spirometry (<30%). UTE MRI suggests increased odds of bronchial changes when mucus plugging is present in the same lobe. MBW and 129Xe MRI correlated best with mucus plugging, while spirometry correlated best with consolidations. Bronchial abnormalities were associated with future pulmonary exacerbations. CONCLUSIONS MBW, 129Xe MRI, and UTE MRI are more sensitive for detection of pediatric CF lung disease when compared to spirometry. MBW and 129Xe MRI correlated with structural abnormalities which occur in early CF disease, suggesting MBW and 129Xe MRI are valuable tools in mild CF lung disease that can guide clinical decision making.
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Affiliation(s)
- Matthew M Willmering
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - David J Roach
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - Elizabeth L Kramer
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, OH 45229, United States
| | - Laura L Walkup
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, OH 45229, United States; Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH 45229, United States
| | - Zackary I Cleveland
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, OH 45229, United States; Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH 45229, United States
| | - Jason C Woods
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, OH 45229, United States; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Physics, University of Cincinnati, Cincinnati, OH 45229, United States.
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9
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Ishak A, Stick SM, Turkovic L, Ranganathan SC, King L, Harrison J, Sly PD, Caudri D, Schultz A. BAL Inflammatory Markers Can Predict Pulmonary Exacerbations in Children With Cystic Fibrosis. Chest 2020; 158:2314-2322. [DOI: 10.1016/j.chest.2020.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022] Open
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10
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[Cystic fibrosis and computed tomography of the lungs]. Radiologe 2020; 60:791-801. [PMID: 32621155 DOI: 10.1007/s00117-020-00713-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
With its high detail of morphological changes in lung parenchyma and airways as well as the possibilities for three-dimensional reconstruction, computed tomography (CT) represents a solid tool for the diagnosis and follow-up in patients suffering from cystic fibrosis (CF). Guidelines for standardized CT image acquisition in CF patients are still missing. In the mostly younger CF patients, an important issue is the well-considered use of radiation in CT imaging. The use of intravenous contrast agent is mainly restricted to acute emergency diagnostics. Typical morphological findings in CF lung disease are bronchiectasis, mucus plugging, or signs of decreased ventilation (air trapping) which can be detected with CT even in early stages. Various scoring systems that have become established over time are used to grade disease severity and for structured follow-up, e.g., in clinical research studies. With the technical development of CT, a number of postprocessing software tools were developed to help clinical reporting and overcome interreader differences for a standardized quantification. As an imaging modality free of ionizing radiation, magnetic resonance imaging (MRI) is becoming increasingly important in the diagnosis and follow-up of CF patients and is already frequently a substitute for CT for long-term follow-up at numerous specialized centers.
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11
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Diab-Cáceres L, Girón-Moreno RM, García-Castillo E, Pastor-Sanz MT, Olveira C, García-Clemente MM, Nieto-Royo R, Prados-Sánchez C, Caballero-Sánchez P, Olivera-Serrano MJ, Padilla-Galo A, Nava-Tomas E, Esteban-Peris A, Fernández-Velilla M, Torres M, Gómez-Punter RM, Ancochea J. Predictive value of the modified Bhalla score for assessment of pulmonary exacerbations in adults with cystic fibrosis. Eur Radiol 2020; 31:112-120. [PMID: 32740815 DOI: 10.1007/s00330-020-07095-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 04/19/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The objective of this study was to analyze the predictive value of the modified Bhalla score in high-resolution computed tomography (HRCT) for assessment of pulmonary exacerbations (PEx) in cystic fibrosis (CF) patients. We also describe the relationship between this score and pulmonary function test results. METHODS We performed a multicenter and prospective study where adult patients with CF were included consecutively over 18 months. All patients underwent HRCT with acquisition in inspiration and expiration. The results were analyzed by an expert radiologist who assigned a modified Bhalla score value. Lung function was also assessed, and clinical variables were collected. Follow-up lasted approximately 1 year, and PEx were registered. RESULTS The study population comprised 160 subjects selected from 360 CF patients monitored in the participating CF units. The mean age was 28 years, 47.5% were women, and mean forced expiratory volume in 1 s (FEV1) was 67.5%. The mean global modified Bhalla score was 14.5 ± 0.31 points. Pulmonary function test (PFT) results and the modified Bhalla score correlated well, mainly forced vital capacity (FVC) and FEV1. We constructed a statistical model based on the overall Bhalla score to predict the number of PEx. CONCLUSIONS The overall modified Bhalla score can predict future PEx in CF patients. This useful tool can help to prevent PEx in higher risk patients. KEY POINTS • Pulmonary function test results and the modified Bhalla score correlated well with FVC and FEV1. • The total modified Bhalla score can predict the number of exacerbations in adult CF patients. • Our findings highlight the need to establish a unified protocol for chest HRCT during the follow-up of adult patients with CF in order to anticipate possible complications and determine their impact on pulmonary function.
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Affiliation(s)
| | | | | | | | - Casilda Olveira
- Respirology Service, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | - Rosa Nieto-Royo
- Respirology Service, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | | | | | - Alicia Padilla-Galo
- Radiodiagnostic Service, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | | | - Maribel Torres
- Radiodiagnostic Service, Hospital Universitario La Paz, Madrid, Spain
| | | | - Julio Ancochea
- Respirology Service, Hospital Universitario La Princesa, Madrid, Spain
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12
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Thomas M, Raja M, Albakri M, Najim M, Chandra P, Allangawi M. CT score and correlation with lung function and microbiology of adult patients with cystic fibrosis with predominant I1234V genotype in Qatar. Qatar Med J 2020; 2020:4. [PMID: 32300549 PMCID: PMC7147265 DOI: 10.5339/qmj.2020.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/29/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Computed tomography (CT) features of cystic fibrosis (CF) lung disease can be objectively quantified using current CT scoring systems to assess the extent and severity of the disease. The aims of this study were to calculate the Santamaria CT scores in adult patients with CF with the predominant CFTR I1234V genotype, determine its reliability, and correlate these parameters with lung function, microbial colonization, compliance to treatment, and exacerbations. Methodology: This retrospective observational study was conducted on adult patients with CF who were regularly followed up in the adult CF service at Qatar via CT scans that were taken not during an acute exacerbation. CT scans were scored using the Santamaria scoring system. Corresponding spirometry, microbiological data of sputum culture, and relevant clinical data were correlated with individual CT scores. Results: Only 23 of the 31 patients underwent CT when not in an acute exacerbation and were included in the study analysis. A total of 20 (87%) patients had the I1234V genotype. There was good agreement between the two radiologists on the Santamaria CT scores with an intraclass correlation coefficient (ICC) value of 0.991. Bronchiectasis was the most consistent finding, followed by interlobular and intralobular septal thickening. Patients with poor lung function and frequent exacerbations had significantly higher CT scores (p = 0.015). The CT scores of patients colonized with Pseudomonas aeruginosa were higher but nonsignificant (p = 0.20). The mean CT scores were significantly higher in patients who were noncompliant to regular treatment than in those who were compliant (p = 0.012). Conclusion: Santamaria CT scores comprise a reliable scoring system for adult patients with CF and can be used to determine the extent and severity of lung disease. P. aeruginosa colonization causes more structural lung damage than other common colonizing organisms. Noncompliance to treatment has a significant impact on the increasing severity of CF lung disease.
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Affiliation(s)
| | | | - Mutaz Albakri
- Department of Chest, Hamad General Hospital, Doha, Qatar
| | - Mostafa Najim
- Department of Medicine, Hamad General Hospital, Doha, Qatar
| | - Prem Chandra
- Medical Research Centre Hamad Medical Corporation, Doha, Qatar
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13
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Predictive value of computed tomography scoring systems evolution in adults with cystic fibrosis. Eur Radiol 2020; 30:3634-3640. [PMID: 32128619 DOI: 10.1007/s00330-020-06759-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/04/2020] [Accepted: 02/18/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To assess whether the evolution of two consecutive high-resolution computed tomography (HRCT) scores in patients with cystic fibrosis (CF) has prognostic value. METHODS A longitudinal retrospective study was performed to research adult patients with CF. Two consecutive HRCT studies were scored using Bhalla and Brody II scoring scales by two senior radiologists. Annual scoring changes for each scale were calculated and correlated with annual FEV1% decline, with pulmonary exacerbations and number of antibiotic treatments. RESULTS We selected sixty-four adult patients. The median interval between the two HRCTs was 3.88 ± 1.59 years. The mean spirometric values showed dynamic lung volumes lower than the general population; globally, there was a worsening of respiratory function over time. The change in the annual HRCT scores was positive on both scales, indicating a worse structural situation over time. The Brody II scale annual change showed a significant statistical correlation with a decline in the annual FEV1%, exacerbations and number of oral antibiotic treatments. In contrast, for the Bhalla scale, the relationship was moderately inverse with exacerbations and with the number of oral treatments. No statistically significant relationships were found for the change in the annual FEV1% and exacerbations or number of antibiotic treatments. The interobservational and intraobservational agreements were very strong in both scales. CONCLUSIONS The annual evolution of the Brody II HRCT scoring system demonstrated a predictive value and correlated with FEV1% decline, pulmonary exacerbations and oral antibiotic treatments. KEY POINTS • HRCT evolution has prognostic value in cystic fibrosis. • Temporal evolution for the Brody II score is useful for clinical follow-up. • Brody II score changes correlate with FEV1% decline, pulmonary exacerbations and number of antibiotic treatments.
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Bouma NR, Janssens HM, Andrinopoulou E, Tiddens HAWM. Airway disease on chest computed tomography of preschool children with cystic fibrosis is associated with school-age bronchiectasis. Pediatr Pulmonol 2020; 55:141-148. [PMID: 31496137 PMCID: PMC6972540 DOI: 10.1002/ppul.24498] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 08/07/2019] [Indexed: 12/17/2022]
Abstract
Airway wall thickening and mucus plugging are important characteristics of cystic fibrosis (CF) lung disease in the first 5 years of life.The aim of this study is to investigate the association of lung disease in preschool children (age, 2-6) with bronchiectasis and other clinical outcome measures in the school age (age >7). Deidentified computed tomography-scans were annotated using Perth-Rotterdam annotated grid morphometric analysis for CF. Preschool %disease (a composite score of %airway wall thickening, %mucus plugging, and %bronchiectasis) and %MUPAT (a composite score of %airway wall thickening and %mucus plugging) were used as predictors for %bronchiectasis and several other school-age clinical outcomes. For statistical analysis, we used regression analysis, linear mixed-effects models and two-way mixed models. Sixty-one patients were included. %Disease increased significantly with age (P < .01). Preschool %disease and %MUPAT were significantly associated with school-age %bronchiectasis (P < .01 and P < .01, respectively). No significant association was found between preschool %disease and %MUPAT and school-age forced expiratory volume 1 (FEV1%) predicted and quality of life (P > .05). Cross-sectional, %disease in school-age was associated with a low FEV1% predicted and low quality of life (P = .01 and P = .007, respectively). %Disease can be considered an early marker of diffuse airways disease and is a risk factor for school-age bronchiectasis.
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Affiliation(s)
- Nynke R. Bouma
- Pediatric Pulmonology and AllergologySophia Children's HospitalRotterdamThe Netherlands
| | - Hettie M. Janssens
- Pediatric Pulmonology and AllergologySophia Children's HospitalRotterdamThe Netherlands
| | | | - Harm A. W. M. Tiddens
- Pediatric Pulmonology and AllergologySophia Children's HospitalRotterdamThe Netherlands
- Radiology and Nuclear MedicineErasmus Medical CenterRotterdamThe Netherlands
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15
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Crisafulli E, Teopompi E, Luceri S, Longo F, Tzani P, Pagano P, Ielpo A, Longo C, Di Paolo M, Sverzellati N, Palange P, Chetta A, Pisi G. The value of high-resolution computed tomography (HRCT) to determine exercise ventilatory inefficiency and dynamic hyperinflation in adult patients with cystic fibrosis. Respir Res 2019; 20:78. [PMID: 31014329 PMCID: PMC6480643 DOI: 10.1186/s12931-019-1044-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/07/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction In Cystic Fibrosis (CF), exercise ventilatory inefficiency and dynamic hyperinflation (DH) cause exercise limitation and induce poor exercise tolerance. High-resolution computed tomography (HRCT) of the lung can detect pulmonary abnormalities in CF patients. We aimed to identify the determinants of exercise ventilatory inefficiency and DH using HRCT-derived metrics. Methods Fifty-two adult CF patients were prospectively enrolled; all participants underwent cardio-pulmonary exercise test (CPET) and HRCT. Radiological impairment was evaluated by the Brody II scoring system. Slope and intercept of the minute ventilation/CO2 production (V’E/V’CO2) regression line and the ratio of inspiratory capacity/total lung capacity (IC/TLC) at rest and at peak of exercise were measured. Results Four groups of patients were identified based on the combination of ventilatory efficiency (Vef) or inefficiency (Vin) and the presence/absence of DH. Compared to other groups, CF adults with Vin and DH had worse functional status and higher total (T), bronchiectasis (B) and air trapping (AT) scores at HRCT. Significant correlations were found between V’E/V’CO2 intercept and V’E/V’CO2 slope (ρ − 0.455, p = 0.001) and between V’E/V’CO2 intercept and Δ inspiratory capacity (IC) (ρ − 0.334, p = 0.015). Regression analysis identified AT score (cut-off 7.9, odds ratio-OR 3.50) as the only independent predictor of Vin and T (cut-off 53.6, OR 4.98), B (cut-off 16.1, OR 4.88), airways wall thickening (AWT) (cut-off 13, OR 3.41), and mucous plugging (MP) scores (cut-off 11.7, OR 4.18) as significant predictors of DH. Conclusion In adult CF cohort, values of HRCT metrics are determinants of Vin (AT) and DH (T, B, AWT, MP).
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Affiliation(s)
- Ernesto Crisafulli
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Via Rasori 10, 43126, Parma, Italy.
| | - Elisabetta Teopompi
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Via Rasori 10, 43126, Parma, Italy
| | - Silvia Luceri
- Section of Radiology, Unit of Surgical Sciences, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Longo
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Via Rasori 10, 43126, Parma, Italy.,Cystic Fibrosis Unit, University Hospital of Parma, Parma, Italy
| | - Panagiota Tzani
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Via Rasori 10, 43126, Parma, Italy
| | - Paolo Pagano
- Section of Radiology, Unit of Surgical Sciences, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Antonella Ielpo
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Via Rasori 10, 43126, Parma, Italy
| | - Chiara Longo
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Via Rasori 10, 43126, Parma, Italy
| | - Marcello Di Paolo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Nicola Sverzellati
- Section of Radiology, Unit of Surgical Sciences, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Alfredo Chetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Via Rasori 10, 43126, Parma, Italy
| | - Giovanna Pisi
- Cystic Fibrosis Unit, University Hospital of Parma, Parma, Italy
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Abstract
BACKGROUND Inhalation of the enzyme dornase alfa reduces sputum viscosity and improves clinical outcomes of people with cystic fibrosis. This is an update of a previously published Cochrane Review. OBJECTIVES To determine whether the timing of dornase alfa inhalation (in relation to airway clearance techniques or morning versus evening inhalation) has an impact on objective and subjective measures of clinical efficacy in people with cystic fibrosis. SEARCH METHODS Relevant randomised and quasi-randomised controlled trials were identified from the Cochrane Cystic Fibrosis Trials Register, Physiotherapy Evidence Database (PEDro), clinical trial registries and international cystic fibrosis conference proceedings.Date of the most recent search: 06 June 2018. SELECTION CRITERIA Any trial of dornase alfa in people with cystic fibrosis where timing of inhalation was the randomised element in the trial with either: inhalation before compared to after airway clearance techniques; or morning compared to evening inhalation. DATA COLLECTION AND ANALYSIS Both authors independently selected trials, assessed risk of bias and extracted data with disagreements resolved by discussion. Relevant data were extracted and, where possible, meta-analysed. MAIN RESULTS We identified 115 trial reports representing 55 trials, of which five trials (providing data on 122 participants) met our inclusion criteria. All five trials used a cross-over design. Intervention periods ranged from two to eight weeks. Four trials (98 participants) compared dornase alfa inhalation before versus after airway clearance techniques. Inhalation after instead of before airway clearance did not significantly change forced expiratory volume at one second (very-low quality evidence). Similarly, forced vital capacity (low-quality evidence) and quality of life (very-low quality evidence) were not significantly affected; forced expiratory flow at 25% was significantly worse with dornase alfa inhalation after airway clearance, mean difference -0.17 litres (95% confidence interval -0.28 to -0.05), based on the pooled data from two small trials in children (7 to 19 years) with well-preserved lung function. All other secondary outcomes were statistically non-significant.In one trial (25 participants), morning versus evening inhalation had no impact on lung function or symptoms (low-quality evidence). AUTHORS' CONCLUSIONS The current evidence derived from a small number of participants does not indicate that inhalation of dornase alfa after airway clearance techniques is more or less effective than the traditional recommendation to inhale nebulised dornase alfa 30 minutes prior to airway clearance techniques, for most outcomes. For children with well-preserved lung function, inhalation before airway clearance may be more beneficial for small airway function than inhalation after. However, this result relied on a measure with high variability and trials with variable follow-up. In the absence of strong evidence to indicate that one timing regimen is better than another, the timing of dornase alfa inhalation can be largely based on pragmatic reasons or individual preference with respect to the time of airway clearance and time of day. Further research is warranted.
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Affiliation(s)
- Ruth Dentice
- Royal Prince Alfred HospitalDepartment of Respiratory MedicineLevel 11, E BlockMissenden RoadCamperdownNew South WalesAustraliaNSW 2050
| | - Mark Elkins
- University of SydneySydney Medical SchoolEdward Ford Building A27SydneyAustraliaNSW 2006
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Mayer-Hamblett N, Retsch-Bogart G, Kloster M, Accurso F, Rosenfeld M, Albers G, Black P, Brown P, Cairns A, Davis SD, Graff GR, Kerby GS, Orenstein D, Buckingham R. Azithromycin for Early Pseudomonas Infection in Cystic Fibrosis. The OPTIMIZE Randomized Trial. Am J Respir Crit Care Med 2018; 198:1177-1187. [PMID: 29890086 PMCID: PMC6221579 DOI: 10.1164/rccm.201802-0215oc] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 06/06/2018] [Indexed: 12/23/2022] Open
Abstract
RATIONALE New isolation of Pseudomonas aeruginosa (Pa) is generally treated with inhaled antipseudomonal antibiotics such as tobramycin inhalation solution (TIS). A therapeutic approach that complements traditional antimicrobial therapy by reducing the risk of pulmonary exacerbation and inflammation may ultimately prolong the time to Pa recurrence. OBJECTIVES To test the hypothesis that the addition of azithromycin to TIS in children with cystic fibrosis and early Pa decreases the risk of pulmonary exacerbation and prolongs the time to Pa recurrence. METHODS The OPTIMIZE (Optimizing Treatment for Early Pseudomonas aeruginosa Infection in Cystic Fibrosis) trial was a multicenter, double-blind, randomized, placebo-controlled, 18-month trial in children with CF, 6 months to 18 years of age, with early Pa. Azithromycin or placebo was given 3× weekly with standardized TIS. MEASUREMENTS AND MAIN RESULTS The primary endpoint was the time to pulmonary exacerbation requiring antibiotics and the secondary endpoint was the time to Pa recurrence, in addition to other clinical and safety outcomes. A total of 221 participants (111 placebo, 110 azithromycin) out of a planned 274 were enrolled. Enrollment was stopped early by the NHLBI because the trial had reached the prespecified interim boundary for efficacy. The risk of pulmonary exacerbation was reduced by 44% in the azithromycin group as compared with the placebo group (hazard ratio, 0.56; 95% confidence interval, 0.37-0.83; P = 0.004). Weight increased by 1.27 kg in the azithromycin group compared with the placebo group (95% confidence interval, 0.01-2.52; P = 0.046). No significant differences were seen in microbiological or other clinical or safety endpoints. CONCLUSIONS Azithromycin was associated with a significant reduction in the risk of pulmonary exacerbation and a sustained improvement in weight, but had no impact on microbiological outcomes in children with early Pa. Clinical trial registered with clinicaltrials.gov (NCT02054156).
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Affiliation(s)
- Nicole Mayer-Hamblett
- Department of Pediatrics and
- Department of Biostatistics, University of Washington, Seattle, Washington
- Seattle Children’s Hospital, Seattle, Washington
| | - George Retsch-Bogart
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | | | - Frank Accurso
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
- Children’s Hospital Colorado, Aurora, Colorado
| | - Margaret Rosenfeld
- Department of Pediatrics and
- Seattle Children’s Hospital, Seattle, Washington
| | - Gary Albers
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Philip Black
- Children’s Mercy Hospital, Kansas City, Missouri
| | - Perry Brown
- St. Luke’s Regional Medical Center, Boise, Idaho
| | | | - Stephanie D. Davis
- Indiana University Hospital, Indianapolis, Indiana
- James Whitcomb Riley Hospital for Children, Indianapolis, Indiana
| | - Gavin R. Graff
- Hershey Medical Center, Hershey, Pennsylvania
- Penn State Children’s Hospital, Hershey, Pennsylvania; and
| | - Gwendolyn S. Kerby
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
- Children’s Hospital Colorado, Aurora, Colorado
| | - David Orenstein
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - for the OPTIMIZE Study Group
- Department of Pediatrics and
- Department of Biostatistics, University of Washington, Seattle, Washington
- Seattle Children’s Hospital, Seattle, Washington
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
- Children’s Hospital Colorado, Aurora, Colorado
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, Missouri
- Children’s Mercy Hospital, Kansas City, Missouri
- St. Luke’s Regional Medical Center, Boise, Idaho
- Maine Medical Center, Portland, Maine
- Indiana University Hospital, Indianapolis, Indiana
- James Whitcomb Riley Hospital for Children, Indianapolis, Indiana
- Hershey Medical Center, Hershey, Pennsylvania
- Penn State Children’s Hospital, Hershey, Pennsylvania; and
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Sanders DB, Li Z, Parker-McGill K, Farrell P, Brody AS. Quantitative chest computerized tomography and FEV 1 equally identify pulmonary exacerbation risk in children with cystic fibrosis. Pediatr Pulmonol 2018; 53:1369-1377. [PMID: 30160050 PMCID: PMC7059197 DOI: 10.1002/ppul.24144] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 07/16/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Chest computerized tomography (CT) scores are associated with the frequency of future pulmonary exacerbations in people with cystic fibrosis (CF). However, cut-off values to identify children with mild lung disease with different risks for frequent future pulmonary exacerbations have not been identified. METHODS Chest CT scans were assessed using the Brody score for participants of the Pulmozyme Early Intervention Trial (PEIT) and Wisconsin Randomized Clinical Trial of CF Newborn Screening (WI RCT). We determined the area under the receiver operating characteristic (ROC) curve for Brody scores and forced expiratory volume in 1 s (FEV1 ) to compare with the frequency of pulmonary exacerbations up to 10 years later. RESULTS There were 60 participants in the PEIT with mean (SD) age 10.6 (1.7) years at the time of the CT and 81 participants in the WI RCT with mean age 11.5 (3.0) years. The Brody score cut-off that best identified children at-risk for ≥0.3 annual pulmonary exacerbations was 3.6 in the PEIT and 2.1 in the WI RCT. There were no statistical differences between ROC curves for the Brody CT score and FEV1 % predicted in either study (P ≥ 0.4). CONCLUSIONS CT score cut-off values that identify children with CF with mild lung disease at different risks for frequent pulmonary exacerbations over an extended follow up period are similar in separate cohorts. Brody scores and FEV1 % predicted have similar abilities to identify these children, suggesting that FEV1 % predicted alone may be adequate for predicting future frequency of pulmonary exacerbations.
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Affiliation(s)
- Don B Sanders
- Department of Pediatrics, Riley Hospital for Children, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin
| | | | - Philip Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Alan S Brody
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Breuer O, Caudri D, Stick S, Turkovic L. Predicting disease progression in cystic fibrosis. Expert Rev Respir Med 2018; 12:905-917. [PMID: 30173593 DOI: 10.1080/17476348.2018.1519400] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Progressive lung disease is the major cause of morbidity and mortality in patients with cystic fibrosis (CF). Methods of correctly predicting the future progression of lung disease in patients with CF are essential for directing aggressive treatment to prevent loss of lung function and end stage respiratory failure. Areas covered: This review addresses predictors of respiratory disease progression in patients with CF. We searched Web of Science and Medline, with no restriction on publication date, with the search terms 'cystic fibrosis' and 'disease progression', 'lung function decline', 'prognosis', 'prediction/predictive', 'prediction/prognostic scores', 'risk factors', 'outcome measures/endpoints/disease surrogate', 'longitudinal/long term', 'statistical model', and 'survival'. Expert commentary: Forced expiratory volume in 1 sec (FEV1) and rate of FEV1 decline, remain the most significant predictors of mortality in patients with CF while CT scores and airway secretion biomarkers are the main predictors of early CF lung disease. Comprehensive scores incorporating clinical, lung function, imaging and laboratory data will become essential in the future for predicting disease progression and for use in clinical trials. Early interventions may delay the progression of structural lung disease.
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Affiliation(s)
- Oded Breuer
- a Telethon Kids Institute , University of Western Australia , Perth , Australia.,b Department of Respiratory and Sleep Medicine , Princess Margaret Hospital for Children , Perth , Australia
| | - Daan Caudri
- a Telethon Kids Institute , University of Western Australia , Perth , Australia.,b Department of Respiratory and Sleep Medicine , Princess Margaret Hospital for Children , Perth , Australia.,c Department of Pediatrics/Respiratory Medicine , Erasmus MC , Rotterdam , The Netherlands
| | - Stephen Stick
- a Telethon Kids Institute , University of Western Australia , Perth , Australia.,b Department of Respiratory and Sleep Medicine , Princess Margaret Hospital for Children , Perth , Australia
| | - Lidija Turkovic
- a Telethon Kids Institute , University of Western Australia , Perth , Australia
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Abstract
BACKGROUND Dornase alfa is currently used as a mucolytic to treat pulmonary disease (the major cause of morbidity and mortality) in cystic fibrosis. It reduces mucus viscosity in the lungs, promoting improved clearance of secretions. This is an update of a previously published review. OBJECTIVES To determine whether the use of dornase alfa in cystic fibrosis is associated with improved mortality and morbidity compared to placebo or other medications that improve airway clearance, and to identify any adverse events associated with its use. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and abstracts from conferences. Date of the most recent search of the Group's Cystic Fibrosis Register: 23 April 2018.Clinicaltrials.gov and the International Clinical Trials Registry Platform were also searched to identify unpublished or ongoing trials. Date of most recent search: 07 June 2018. SELECTION CRITERIA All randomised and quasi-randomised controlled trials comparing dornase alfa to placebo, standard therapy or other medications that improve airway clearance. DATA COLLECTION AND ANALYSIS Authors independently assessed trials against the inclusion criteria; two authors carried out analysis of methodological quality and data extraction. GRADE was used to assess the level of evidence. MAIN RESULTS The searches identified 69 trials, of which 19 (2565 participants) met our inclusion criteria. Fifteen trials compared dornase alfa to placebo or no dornase alfa (2447 participants); two compared daily dornase to hypertonic saline (32 participants); one compared daily dornase alfa to hypertonic saline and alternate day dornase alfa (48 participants); one compared dornase alfa to mannitol and the combination of both drugs (38 participants). Trial duration varied from six days to three years.Dornase alfa compared to placebo or no treatmentDornase alfa improved forced expiratory volume at one second at one month (four trials, 248 participants), three months (one trial, 320 participants; moderate-quality evidence), six months (one trial, 647 participants; high-quality evidence) and two years (one trial, 410 participants). Limited low-quality evidence showed no difference between groups for changes in quality of life. There was a decrease in pulmonary exacerbations with dornase alfa in trials of up to two years (moderate-quality evidence). One trial that examined the cost of care, including the cost of dornase alfa, found that the cost savings from dornase alfa offset 18% to 38% of the medication costs.Dornase alfa: daily versus alternate dayOne cross-over trial (43 children) found no differences between treatment regimens for lung function, quality of life or pulmonary exacerbations (low-quality evidence).Dornase alfa compared to other medications that improve airway clearanceResults for these comparisons were mixed. One trial (43 children) showed a greater improvement in forced expiratory volume at one second for dornase alfa compared to hypertonic saline (low-quality evidence), and one trial (23 participants) reported no difference in lung function between dornase alfa and mannitol or dornase alfa and dornase alfa plus mannitol (low-quality evidence). One trial (23 participants) found a difference in quality of life favouring dornase alfa when compared to dornase alfa plus mannitol (low-quality evidence); other comparisons found no difference in this outcome (low-quality evidence). No trials in any comparison reported any difference between groups in the number of pulmonary exacerbations (low-quality evidence).When all comparisons are assessed, dornase alfa did not cause significantly more adverse effects than other treatments, except voice alteration and rash. AUTHORS' CONCLUSIONS There is evidence to show that, compared with placebo, therapy with dornase alfa improves lung function in people with cystic fibrosis in trials lasting from one month to two years. There was a decrease in pulmonary exacerbations in trials of six months or longer. Voice alteration and rash appear to be the only adverse events reported with increased frequency in randomised controlled trials. There is not enough evidence to firmly conclude if dornase alfa is superior to other hyperosmolar agents in improving lung function.
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Affiliation(s)
- Connie Yang
- BC Children's HospitalDepartment of Pediatrics, Division of Respiratory Medicine4480 Oak StreetVancouverBCCanadaV6H 3V4
| | - Mark Montgomery
- Alberta Children's HospitalPediatrics and Child Health2888 Shaganappi Trail NWCalgaryABCanadaT3B 6A8
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Schäfer J, Griese M, Chandrasekaran R, Chotirmall SH, Hartl D. Pathogenesis, imaging and clinical characteristics of CF and non-CF bronchiectasis. BMC Pulm Med 2018; 18:79. [PMID: 29788954 PMCID: PMC5964733 DOI: 10.1186/s12890-018-0630-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/25/2018] [Indexed: 12/26/2022] Open
Abstract
Bronchiectasis is a common feature of severe inherited and acquired pulmonary disease conditions. Among inherited diseases, cystic fibrosis (CF) is the major disorder associated with bronchiectasis, while acquired conditions frequently featuring bronchiectasis include post-infective bronchiectasis and chronic obstructive pulmonary disease (COPD). Mechanistically, bronchiectasis is driven by a complex interplay of inflammation and infection with neutrophilic inflammation playing a predominant role. The clinical characterization and management of bronchiectasis should involve a precise diagnostic workup, tailored therapeutic strategies and pulmonary imaging that has become an essential tool for the diagnosis and follow-up of bronchiectasis. Prospective future studies are required to optimize the diagnostic and therapeutic management of bronchiectasis, particularly in heterogeneous non-CF bronchiectasis populations.
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Affiliation(s)
- Jürgen Schäfer
- Department of Radiology, Division of Pediatric Radiology, University of Tübingen, Tübingen, Germany.
| | | | | | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Dominik Hartl
- Department of Pediatrics I, University of Tübingen, Tübingen, Germany.,Roche Pharma Research & Early Development (pRED), Immunology, Inflammation and Infectious Diseases (I3) Discovery and Translational Area, Roche Innovation Center, Basel, Switzerland
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22
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Kuo W, Soffers T, Andrinopoulou ER, Rosenow T, Ranganathan S, Turkovic L, Stick SM, Tiddens HAWM. Quantitative assessment of airway dimensions in young children with cystic fibrosis lung disease using chest computed tomography. Pediatr Pulmonol 2017; 52:1414-1423. [PMID: 28881106 DOI: 10.1002/ppul.23787] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 07/06/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate lung disease progression using airway and artery (AA) dimensions on chest CT over 2-year interval in young CF patients longitudinally and compare to disease controls cross-sectionally. METHODS Retrospective analysis of pressure controlled end-inspiratory CTs, 12 routine baseline (CT1 ) and follow up (CT2 ) from AREST CF cohort; 12 disease controls with normal CT. All visible AA-pairs were measured perpendicular to the airway axis. Inner and outer airway diameters and wall (outer-inner radius) thickness were divided by adjacent arteries to compute Ain A-, Aout A-, and AWT A-ratios, respectively. Differences between CF and control data were assessed using mixed effects models predicting AA-ratios per segmental generation (SG). Power calculations were performed with 80% power and ɑ = 0.05. RESULTS CF, median age CT1 2 years; CT2 3.9 years, 5 males. Controls, median age 2.9 years, 10 males. Total of 4798 AA-pairs measured. Cross-sectionally: Ain A-ratio showed no difference between controls and CF CT1 or CT2 . Aout A-ratio was significantly higher in CF CT1 (SG 2-4) and CT2 (SG 2-5) compared to controls. AWT A-ratio was increased for CF CT1 (SG 1-5) and CT2 (SG 2-6) compared to controls. CF longitudinally: Ain A-ratio was significantly higher at CT2 compared to CT1 . Increase in Aout A-ratio at CT2 compared to CT1 was visible in SG ≥4. Sample sizes of 21 and 58 would be necessary for 50% and 30% Aout A-ratio reductions, respectively, between CF CT2 and controls. CONCLUSION AA-ratio differences were present in young CF patients relative to disease controls. Aout A-ratio as an objective parameter for bronchiectasis could reduce sample sizes for clinical trials.
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Affiliation(s)
- Wieying Kuo
- Department of Pediatric Pulmonology and Allergology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - Thomas Soffers
- Department of Pediatric Pulmonology and Allergology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Tim Rosenow
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Sarath Ranganathan
- Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Australia.,Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Australia
| | - Lidija Turkovic
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Stephen M Stick
- Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Harm A W M Tiddens
- Department of Pediatric Pulmonology and Allergology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, The Netherlands
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23
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Athanazio RA, Silva Filho LVRFD, Vergara AA, Ribeiro AF, Riedi CA, Procianoy EDFA, Adde FV, Reis FJC, Ribeiro JD, Torres LA, Fuccio MBD, Epifanio M, Firmida MDC, Damaceno N, Ludwig-Neto N, Maróstica PJC, Rached SZ, Melo SFDO. Brazilian guidelines for the diagnosis and treatment of cystic fibrosis. ACTA ACUST UNITED AC 2017; 43:219-245. [PMID: 28746534 PMCID: PMC5687954 DOI: 10.1590/s1806-37562017000000065] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/22/2017] [Indexed: 12/15/2022]
Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic disorder characterized by dysfunction of the CFTR gene. It is a multisystem disease that most often affects White individuals. In recent decades, various advances in the diagnosis and treatment of CF have drastically changed the scenario, resulting in a significant increase in survival and quality of life. In Brazil, the current neonatal screening program for CF has broad coverage, and most of the Brazilian states have referral centers for the follow-up of individuals with the disease. Previously, CF was limited to the pediatric age group. However, an increase in the number of adult CF patients has been observed, because of the greater number of individuals being diagnosed with atypical forms (with milder phenotypic expression) and because of the increase in life expectancy provided by the new treatments. However, there is still great heterogeneity among the different regions of Brazil in terms of the access of CF patients to diagnostic and therapeutic methods. The objective of these guidelines was to aggregate the main scientific evidence to guide the management of these patients. A group of 18 CF specialists devised 82 relevant clinical questions, divided into five categories: characteristics of a referral center; diagnosis; treatment of respiratory disease; gastrointestinal and nutritional treatment; and other aspects. Various professionals working in the area of CF in Brazil were invited to answer the questions devised by the coordinators. We used the PubMed database to search the available literature based on keywords, in order to find the best answers to these questions.
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Affiliation(s)
- Rodrigo Abensur Athanazio
- . Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Alberto Andrade Vergara
- . Hospital Infantil João Paulo II, Rede Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | | | | | | | - Fabíola Villac Adde
- . Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Francisco José Caldeira Reis
- . Hospital Infantil João Paulo II, Rede Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | - José Dirceu Ribeiro
- . Hospital de Clínicas, Universidade Estadual de Campinas, Campinas (SP) Brasil
| | - Lídia Alice Torres
- . Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Marcelo Bicalho de Fuccio
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
| | - Matias Epifanio
- . Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre (RS) Brasil
| | | | - Neiva Damaceno
- . Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo (SP) Brasil
| | - Norberto Ludwig-Neto
- . Hospital Infantil Joana de Gusmão, Florianópolis (SC) Brasil.,. Serviço de Fibrose Cística e Triagem Neonatal para Fibrose Cística, Secretaria Estadual de Saúde de Santa Catarina, Florianópolis (SC) Brasil
| | - Paulo José Cauduro Maróstica
- . Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil.,. Universidade Federal do Rio Grande do Sul Porto Alegre (RS) Brasil
| | - Samia Zahi Rached
- . Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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24
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Ciet P, Bertolo S, Ros M, Andrinopoulou ER, Tavano V, Lucca F, Feiweier T, Krestin GP, Tiddens HAWM, Morana G. Detection and monitoring of lung inflammation in cystic fibrosis during respiratory tract exacerbation using diffusion-weighted magnetic resonance imaging. Eur Respir J 2017; 50:50/1/1601437. [PMID: 28729470 DOI: 10.1183/13993003.01437-2016] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 04/10/2017] [Indexed: 01/15/2023]
Abstract
The aim was to investigate whether diffusion-weighted magnetic resonance imaging (DWI) detects and monitors inflammatory and lung function changes during respiratory tract exacerbations (RTE) treatment in patients with cystic fibrosis (CF).29 patients with RTE underwent DWI pre- and post-antibiotic treatment. A control group of 27 stable patients, matched for age and sex, underwent DWI with the same time gap as those undergoing RTE treatment. Clinical status and lung function were assessed at each DWI time point. The CF-MRI scoring system was used to assess structural lung changes in both CF groups.Significant reduction in the DWI score over the course of antibiotic treatment (p<0.0001) was observed in patients with RTE, but not in the control group. DWI score had a strong inverse correlation with clinical status (r=-0.504, p<0.0001) and lung function (r=-0.635, p<0.0001) in patients with RTE. Interestingly, there were persistent significant differences in the CF-MRI score between the RTE and control group at both baseline and follow-up (p<0.001), while the differences in DWI score were only observed at baseline (p<0.001).DWI is a promising imaging method for noninvasive detection of pulmonary inflammation during RTE, and may be used to monitor treatment efficacy of anti-inflammatory treatment.
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Affiliation(s)
- Pierluigi Ciet
- Dept of Radiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Dept of Pediatrics, Respiratory Medicine and Allergology, Erasmus Medical Center, Rotterdam, the Netherlands.,Dept of Radiology, Ca'Foncello Regional Hospital, Treviso, Italy
| | - Silvia Bertolo
- Dept of Radiology, Ca'Foncello Regional Hospital, Treviso, Italy
| | - Mirco Ros
- Dept of Pediatrics, Ca'Foncello Regional Hospital, Treviso, Italy
| | | | - Valentina Tavano
- Dept of Radiology, Ca'Foncello Regional Hospital, Treviso, Italy
| | - Francesca Lucca
- Dept of Women's and Children's Health, University of Padova, Padova, Italy
| | | | - Gabriel P Krestin
- Dept of Radiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Harm A W M Tiddens
- Dept of Radiology, Erasmus Medical Center, Rotterdam, the Netherlands.,Dept of Pediatrics, Respiratory Medicine and Allergology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Giovanni Morana
- Dept of Radiology, Ca'Foncello Regional Hospital, Treviso, Italy
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25
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A semiquantitative MRI-Score can predict loss of lung function in patients with cystic fibrosis: Preliminary results. Eur Radiol 2017; 28:74-84. [PMID: 28664245 DOI: 10.1007/s00330-017-4870-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/28/2017] [Accepted: 04/27/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To evaluate the applicability of a semiquantitative MRI scoring system (MR-CF-S) as a prognostic marker for clinical course of cystic fibrosis (CF) lung disease. METHODS This observational study of a single-centre CF cohort included a group of 61 patients (mean age 12.9 ± 4.7 years) receiving morphological and functional pulmonary MRI, pulmonary function testing (PFT) and follow-up of 2 years. MRI was analysed by three raters using MR-CF-S. The inter-rater agreement, correlation of score categories with forced expiratory volume in 1 s (FEV1) at baseline, and the predictive value of clinical parameters, and score categories was assessed for the whole cohort and a subgroup of 40 patients with moderately impaired lung function. RESULTS The inter-rater agreement of MR-CF-S was sufficient (mean intraclass correlation coefficient 0.92). MR-CF-S (-0.62; p < 0.05) and most of the categories significantly correlated with FEV1. Differences between patients with relevant loss of FEV1 (>3%/year) and normal course were only significant for MR-CF-S (p < 0.05) but not for clinical parameters. Centrilobular opacity (CO) was the most promising score category for prediction of a decline of FEV1 (area under curve: whole cohort 0.69; subgroup 0.86). CONCLUSIONS MR-CF-S is promising to predict a loss of lung function. CO seems to be a particular finding in CF patients with an abnormal course. KEY POINTS • Lung imaging is essential in the diagnostic work-up of CF patients • MRI serves as a powerful, radiation-free modality in paediatric CF patients • Observational single-centre study showed significant correlation of MR-CF score and FEV 1 • MR-CF score is promising in predicting a loss of lung function.
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26
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DeBoer EM, Kroehl ME, Wagner BD, Accurso FJ, Harris JK, Lynch DA, Sagel SD, Deterding RR. Proteomic profiling identifies novel circulating markers associated with bronchiectasis in cystic fibrosis. Proteomics Clin Appl 2017; 11. [DOI: 10.1002/prca.201600147] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/20/2017] [Accepted: 04/25/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Emily M. DeBoer
- Department of Pediatrics; University of Colorado Anschutz Medical Campus and Children's Hospital Colorado; USA
| | - Miranda E. Kroehl
- Department of Biostatistics and Informatics; University of Colorado School of Public Health; USA
| | - Brandie D. Wagner
- Department of Pediatrics; University of Colorado Anschutz Medical Campus and Children's Hospital Colorado; USA
- Department of Biostatistics and Informatics; University of Colorado School of Public Health; USA
| | - Frank J. Accurso
- Department of Pediatrics; University of Colorado Anschutz Medical Campus and Children's Hospital Colorado; USA
| | - J. Kirk Harris
- Department of Pediatrics; University of Colorado Anschutz Medical Campus and Children's Hospital Colorado; USA
| | - David A. Lynch
- Department of Radiology; National Jewish Health; Denver USA
| | - Scott D. Sagel
- Department of Pediatrics; University of Colorado Anschutz Medical Campus and Children's Hospital Colorado; USA
| | - Robin R. Deterding
- Department of Pediatrics; University of Colorado Anschutz Medical Campus and Children's Hospital Colorado; USA
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27
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Abstract
BACKGROUND Inhalation of the enzyme dornase alfa reduces sputum viscosity and improves clinical outcomes of people with cystic fibrosis. This is an update of a previously published Cochrane review. OBJECTIVES To determine the effect of timing of dornase alfa inhalation on measures of clinical efficacy in people with cystic fibrosis (in relation to airway clearance techniques or time of day). SEARCH METHODS Relevant randomised and quasi-randomised controlled trials were identified from the Cochrane Cystic Fibrosis Trials Register, Physiotherapy Evidence Database (PEDro), and international cystic fibrosis conference proceedings.Date of the most recent search: 25 April 2016. SELECTION CRITERIA Any trial of dornase alfa in people with cystic fibrosis where timing of inhalation was the randomised element in the study with either: inhalation before compared to after airway clearance techniques; or morning compared to evening inhalation. DATA COLLECTION AND ANALYSIS Both authors independently selected trials, assessed risk of bias and extracted data with disagreements resolved by discussion. Relevant data were extracted and, where possible, meta-analysed. MAIN RESULTS We identified 115 trial reports representing 55 studies, of which five studies (providing data on 122 participants) met our inclusion criteria. All five studies used a cross-over design. Intervention periods ranged from two to eight weeks. Four trials compared dornase alfa inhalation before versus after airway clearance techniques. Inhalation after instead of before airway clearance did not significantly change forced expiratory volume at one second. Similarly, forced vital capacity and quality of life were not significantly affected; forced expiratory flow at 25% was significantly worse with dornase alfa inhalation after airway clearance, mean difference -0.17 litres (95% confidence interval -0.28 to -0.05), based on the pooled data from two small studies in children (seven to 19 years) with well-preserved lung function. All other secondary outcomes were statistically non-significant.In one trial, morning versus evening inhalation had no impact on lung function or symptoms. AUTHORS' CONCLUSIONS The current evidence derived from a small number of participants does not indicate that inhalation of dornase alfa after airway clearance techniques is more or less effective than the traditional recommendation to inhale nebulised dornase alfa 30 minutes prior to airway clearance techniques, for most outcomes. For children with well-preserved lung function, inhalation before airway clearance may be more beneficial for small airway function than inhalation after. However, this result relied on a measure with high variability and studies with variable follow up. In the absence of strong evidence to indicate that one timing regimen is better than another, the timing of dornase alpha inhalation can be largely based on pragmatic reasons or individual preference with respect to the time of airway clearance and time of day. Further research is warranted.
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Affiliation(s)
- Ruth Dentice
- Royal Prince Alfred HospitalDepartment of Respiratory MedicineLevel 11, E BlockMissenden RoadCamperdownAustraliaNSW 2050
| | - Mark Elkins
- University of SydneySydney Medical SchoolEdward Ford Building A27SydneyAustraliaNSW 2006
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28
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Savant AP, McColley SA. Pediatric Pulmonology year in review 2015: Part 4. Pediatr Pulmonol 2016; 51:754-65. [PMID: 27171478 DOI: 10.1002/ppul.23470] [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: 04/22/2016] [Accepted: 05/02/2016] [Indexed: 11/06/2022]
Abstract
In this article, we highlight cystic fibrosis (CF) research published in Pediatric Pulmonology during 2015. Articles from other journals that reflect similar themes, and those of special importance, are also included. Pediatr Pulmonol. 2016;51:754-765. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Adrienne P Savant
- Division of Pulmonary Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Susanna A McColley
- Division of Pulmonary Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Chicago, Illinois
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29
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Gomez-Cardona D, Nagle SK, Li K, Robinson TE, Chen GH. Influence of radiation dose and reconstruction algorithm in MDCT assessment of airway wall thickness: A phantom study. Med Phys 2015; 42:5919-27. [PMID: 26429266 PMCID: PMC4575323 DOI: 10.1118/1.4930797] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/25/2015] [Accepted: 08/29/2015] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Wall thickness (WT) is an airway feature of great interest for the assessment of morphological changes in the lung parenchyma. Multidetector computed tomography (MDCT) has recently been used to evaluate airway WT, but the potential risk of radiation-induced carcinogenesis-particularly in younger patients-might limit a wider use of this imaging method in clinical practice. The recent commercial implementation of the statistical model-based iterative reconstruction (MBIR) algorithm, instead of the conventional filtered back projection (FBP) algorithm, has enabled considerable radiation dose reduction in many other clinical applications of MDCT. The purpose of this work was to study the impact of radiation dose and MBIR in the MDCT assessment of airway WT. METHODS An airway phantom was scanned using a clinical MDCT system (Discovery CT750 HD, GE Healthcare) at 4 kV levels and 5 mAs levels. Both FBP and a commercial implementation of MBIR (Veo(TM), GE Healthcare) were used to reconstruct CT images of the airways. For each kV-mAs combination and each reconstruction algorithm, the contrast-to-noise ratio (CNR) of the airways was measured, and the WT of each airway was measured and compared with the nominal value; the relative bias and the angular standard deviation in the measured WT were calculated. For each airway and reconstruction algorithm, the overall performance of WT quantification across all of the 20 kV-mAs combinations was quantified by the sum of squares (SSQs) of the difference between the measured and nominal WT values. Finally, the particular kV-mAs combination and reconstruction algorithm that minimized radiation dose while still achieving a reference WT quantification accuracy level was chosen as the optimal acquisition and reconstruction settings. RESULTS The wall thicknesses of seven airways of different sizes were analyzed in the study. Compared with FBP, MBIR improved the CNR of the airways, particularly at low radiation dose levels. For FBP, the relative bias and the angular standard deviation of the measured WT increased steeply with decreasing radiation dose. Except for the smallest airway, MBIR enabled significant reduction in both the relative bias and angular standard deviation of the WT, particularly at low radiation dose levels; the SSQ was reduced by 50%-96% by using MBIR. The optimal reconstruction algorithm was found to be MBIR for the seven airways being assessed, and the combined use of MBIR and optimal kV-mAs selection resulted in a radiation dose reduction of 37%-83% compared with a reference scan protocol with a dose level of 1 mGy. CONCLUSIONS The quantification accuracy of airway WT is strongly influenced by radiation dose and reconstruction algorithm. The MBIR algorithm potentially allows the desired WT quantification accuracy to be achieved with reduced radiation dose, which may enable a wider clinical use of MDCT for the assessment of airway WT, particularly for younger patients who may be more sensitive to exposures with ionizing radiation.
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Affiliation(s)
- Daniel Gomez-Cardona
- Department of Medical Physics, University of Wisconsin-Madison School of Medicine and Public Health, 1111 Highland Avenue, Madison, Wisconsin 53705
| | - Scott K Nagle
- Department of Medical Physics, University of Wisconsin-Madison School of Medicine and Public Health, 1111 Highland Avenue, Madison, Wisconsin 53705; Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, Wisconsin 53792; and Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, Wisconsin 53792
| | - Ke Li
- Department of Medical Physics, University of Wisconsin-Madison School of Medicine and Public Health, 1111 Highland Avenue, Madison, Wisconsin 53705 and Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, Wisconsin 53792
| | - Terry E Robinson
- Department of Pediatrics, Stanford School of Medicine, 770 Welch Road, Palo Alto, California 94304
| | - Guang-Hong Chen
- Department of Medical Physics, University of Wisconsin-Madison School of Medicine and Public Health, 1111 Highland Avenue, Madison, Wisconsin 53705 and Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, Wisconsin 53792
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30
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VanDevanter DR, Pasta DJ, Konstan MW. Treatment and demographic factors affecting time to next pulmonary exacerbation in cystic fibrosis. J Cyst Fibros 2015; 14:763-9. [PMID: 25754096 DOI: 10.1016/j.jcf.2015.02.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/10/2015] [Accepted: 02/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pulmonary exacerbations (PEx) are important CF clinical events. METHODS We studied time to next PEx following intravenous (IV) antibiotic PEx treatment among Cleveland Ohio CF center patients occurring between January 2010 and September 2014. Patient demographics, clinical presentations, and treatments were modeled by Cox proportional hazards regression to identify covariates associated with time to next PEx. RESULTS 193 patients were treated for PEx; 155 had a subsequent IV-treated PEx. Six covariates were associated with future PEx hazard: number of PEx in the prior year (hazard ratio 25.1 for ≥3 and 4.4 for 1-2 prior-year PEx versus none; P<.0001), IV treatment duration in weeks (1.2; P=.0004), percent hospital treatment (1.1; P=.0018), and chronic inhaled aminoglycosides (2.5; P<.0001), leukotriene modifiers (1.8; P=.0031), and high dose ibuprofen (0.52; P=.0006). CONCLUSIONS Time to next PEx was profoundly associated with prior-year PEx, suggestive of high-risk PEx phenotypes that warrant recognition and further study.
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Affiliation(s)
| | | | - Michael W Konstan
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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