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Miles C, Ling N, Paul E, Armstrong D. Presentation, characteristics and management of obstructive intestinal conditions in cystic fibrosis. Frontline Gastroenterol 2024; 15:222-227. [PMID: 38665789 PMCID: PMC11042455 DOI: 10.1136/flgastro-2023-102533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/21/2023] [Indexed: 04/28/2024] Open
Abstract
Objective Constipation and distal intestinal obstruction syndrome (DIOS) are common gastrointestinal manifestations of cystic fibrosis (CF). The primary aim was to describe the characteristics of constipation and DIOS hospitalisations in a paediatric and adult CF service over a 12-year period. The secondary aims were to determine the proportion of constipation and DIOS presentations which met the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) CF Working Group definitions and to describe management strategies of both conditions. Method A retrospective study of children and adults with CF who were admitted with a primary diagnosis of constipation or DIOS between 1 January 2011 and 31 December 2022. ESPGHAN definitions for constipation and DIOS were retrospectively applied to all admissions to determine if the primary medical diagnosis met ESPGHAN criteria. Results During the 12-year study period, 42 hospitalisations for constipation were recorded in 19 patients, and 33 hospitalisations for DIOS were recorded in 23 patients. 88.10% of constipation episodes met ESPGHAN definitions, compared with 3.0% of DIOS episodes. Constipation and DIOS were primarily treated with polyethylene glycol (PEG). The use of sodium amidotrizoate meglumine enemas was significantly higher in the DIOS group (p=0.045). Those admitted with DIOS were significantly less likely to be recommended a weaning dose of PEG (p=0.018). Conclusion Children and adults with CF are more commonly admitted for the management of constipation than DIOS. There is considerable variation in diagnostic and therapeutic practice, and this study highlights the need to enhance the translation and adoption of existing best-practice guidelines.
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Affiliation(s)
- Caitlin Miles
- Nutrition and Dietetics, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Natalie Ling
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Eldho Paul
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Melbourne, Victoria, Australia
| | - David Armstrong
- Department of Respiratory and Sleep Medicine, Monash Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
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Wajda KE, Roesch EA, Gifford AH. Chronic daily respiratory care needs in people with cystic fibrosis treated with highly effective cystic fibrosis transmembrane conductance regulator modulators. Curr Opin Pulm Med 2023; 29:580-586. [PMID: 37611027 DOI: 10.1097/mcp.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
PURPOSE OF REVIEW Cystic fibrosis is a genetic disease that increases risk of death from respiratory failure because of impairment in mucociliary clearance. Complex daily care regimens including medications and airway clearance techniques (ACTs) aim to preserve lung function and alleviate symptoms for people with cystic fibrosis (pwCF). The success of highly effective modulator therapy (HEMT) permits evaluation of treatment simplification. In this review, we evaluate adjustments made in daily respiratory care among pwCF taking HEMT and the feasibility of treatment simplification. RECENT FINDINGS Treatment simplification has been identified as a top priority among pwCF, with recent studies showing pwCF are willing to sacrifice mild to moderate amounts of lung function and longevity to reduce treatment burden. Retrospective studies have shown that patients taking HEMT with better baseline lung function have lower adherence to and prescription of inhaled medications. A randomized, controlled trial found that short-term discontinuation of dornase alfa or hypertonic saline was clinically noninferior to continuation of these medications. Major knowledge gaps remain about withdrawing ACTs. SUMMARY This review highlights trials evaluating the feasibility of treatment simplification among pwCF taking HEMT. More data is needed to evaluate approaches to simplification in this phenotypically diverse patient population.
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Affiliation(s)
- Katherine E Wajda
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University Hospitals Cleveland Medical Center
- Department of Pediatrics, Division of Pediatric Pulmonology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Erica A Roesch
- Department of Pediatrics, Division of Pediatric Pulmonology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Alex H Gifford
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University Hospitals Cleveland Medical Center
- Department of Pediatrics, Division of Pediatric Pulmonology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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3
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Sathe M, Moshiree B, Aliaj E, Lee M, Hudson J, Gifford A, Attel S, Gamel B, Freedman SD, Schwarzenberg SJ, Freeman AJ. Need to study simplification of gastrointestinal medication regimen in cystic fibrosis in the era of highly effective modulators. Pediatr Pulmonol 2023; 58:811-818. [PMID: 36448312 DOI: 10.1002/ppul.26257] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/13/2022] [Accepted: 11/25/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION The success of highly effective modulator therapy (HEMT) has led to consideration of simpler regimens for people with CF (PwCF) with opportunities to modify burdensome regimens. Despite the intuitive appeal of discontinuing chronic therapies no longer necessary, this process should be pursued systematically to ensure safety, adherence, and validate patient-centered preferences. We designed a questionnaire to determine the state of use of acid-suppressive medications (ASM) and pancreatic enzyme therapy (PERT), current self-withdrawal and provider-directed withdrawal practices, and interest in a standardized withdrawal study. METHODS In collaboration with CF Foundation (CFF), a questionnaire was developed and distributed to members of Community Voice (CV, comprised of PwCF and their loved ones), and CF providers regarding the need to study simplifying the gastrointestinal (GI) regimen for PwCF on HEMT. RESULTS Approximately 20-40% of CV or CF providers have decreased or stopped ASM for those on HEMT. For PERT, CV and CF providers have decreased dose (34%-48% and approximately 25%, respectively) more often than having stopped it altogether (13%-24% and 3%-12%, respectively). Cumulatively, there is interest in pursuing research in this area (86% CV and 89% CF providers) and willingness to enroll in such a study (80% CV and 89% CF providers). CONCLUSION Systematically studying the withdrawal of common GI medications, ASM and PERT, is important to CV and CF providers. Decreases in dosing and withdrawal are already taking place without evidence to support this practice. This questionnaire is the first step in designing a GI medication simplification study in PwCF on HEMT.
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Affiliation(s)
- Meghana Sathe
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern/Children's Health, Dallas, Texas, USA
| | - Baha Moshiree
- Division of Gastroenterology, Wake Forest/Atrium Health, Charlotte, North Carolina, USA
| | - Enid Aliaj
- Cystic Fibrosis Foundation: Community Partnerships, Bethesda, Maryland, USA
| | - MinJae Lee
- Division of Biostatistics, Department of Population & Data Sciences, University of Texas Southwestern, Dallas, Texas, USA
| | - Jessica Hudson
- Cystic Fibrosis Foundation: Community Partnerships, Bethesda, Maryland, USA
| | - Alex Gifford
- Division of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals Cleveland Medical Center, Ohio, Cleveland, USA.,Division of Pediatric Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Susan Attel
- Patient Representative, Children's Health, Dallas, Texas, USA
| | - Breck Gamel
- Patient Representative, Children's Health, Dallas, Texas, USA
| | - Steven D Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sarah Jane Schwarzenberg
- University of Minnesota/MHealth Fairview Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - A Jay Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital/Ohio State School of Medicine, Columbus, Ohio, USA
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Moshiree B, Freeman AJ, Vu PT, Khan U, Ufret-Vincenty C, Heltshe SL, Goss CH, Schwarzenberg SJ, Freedman SD, Borowitz D, Sathe M. Multicenter prospective study showing a high gastrointestinal symptom burden in cystic fibrosis. J Cyst Fibros 2023; 22:266-274. [PMID: 36319569 PMCID: PMC10147845 DOI: 10.1016/j.jcf.2022.10.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 10/15/2022] [Accepted: 10/16/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND AIMS People with cystic fibrosis (PwCF) suffer from gastrointestinal (GI) symptoms affecting their quality of life (QOL). Despite the relevance of GI symptoms to the overall health of PwCF, a paucity of studies only have comprehensively assessed the prevalence, severity and QOL of GI symptoms in both children and adults with Cystic Fibrosis (CF). METHODS Eligible participants ≥2 years of age across 26 US CF centers were followed for 4 weeks. Three validated GI electronic patient-reported outcome measures (ePROMs) with a recall period of 2 weeks and a stool-specific questionnaire were administered weekly over four weeks. Total and domain scores of ePROMs were evaluated overall and in subgroups using linear mixed-effect models. RESULTS Of 402 enrolled, 58% were ≥ 18 years of age (52% male). The mean (SD) of the total score for PAC-SYM was 0.52 (0.55), for PAGI-SYM was 0.63 (0.67), and for PAC-QOL was 0.67 (0.55). For specific ePROM questions, prevalence of moderate to very severe symptoms were as follows: straining (20.3%), fullness (18.3%), incomplete bowel movements (17.1%), bloating (16.4%), distension (16.4%), abdominal pain (upper-5.1%, lower-7.5%). Comparing participants ≥18 versus <18, a higher prevalence of bloating (63.7% versus 27.3%), lower abdominal pain (39.8% vs 26.2%), stomach fullness (75.6% versus 56.2%), and abdominal distension (60.2% versus 34.9%) was found. Both age groups reported high treatment dissatisfaction as measured with PAC-QOL, mean 1.39 (95% CI: 1.30, 1.47). CONCLUSION GI symptoms were reported in all age ranges irrespective of gender, with higher prevalence observed amongst older and female subgroups. Dissatisfaction with GI targeted treatments were reported in a large proportion of participants despite therapy, highlighting an unmet need for clinical interventions. CLINICALTRIALS GOV: NCT03801993.
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Affiliation(s)
- Baha Moshiree
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Atrium Health, Charlotte, NC, United States.
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital/The Ohio State University, Columbus, OH, United States
| | - Phuong T Vu
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Umer Khan
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Carmen Ufret-Vincenty
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States
| | - Sonya L Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA, United States; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States; Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Sarah Jane Schwarzenberg
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Steven D Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Drucy Borowitz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, United States
| | - Meghana Sathe
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern/Children's Health, Dallas, TX, United States
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Viprey M, Mougeot F, Dima AL, Haesebaert J, Occelli P, Durieu I, Rouzé H, Reynaud Q, Touzet S. A Participatory Approach Involving Patients with Cystic Fibrosis and Healthcare Professionals for the Co-Design of an Adherence-Enhancing Intervention Toolkit. Patient Prefer Adherence 2023; 17:995-1004. [PMID: 37063606 PMCID: PMC10103710 DOI: 10.2147/ppa.s389792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/22/2023] [Indexed: 04/18/2023] Open
Abstract
Purpose Cystic fibrosis (CF) is an inherited life-shortening disease involving a significant treatment burden. Few interventions have been proven effective in improving adherence, and of these fewer have been adopted for implementation. Patient participation in research is increasingly desired in developing relevant health care services. A participatory approach was implemented in an adult CF center to co-design an adherence-enhancing intervention toolkit. We aimed to report on the participatory process and the results regarding the co-designed intervention. Patients and Methods Two focus group sessions and four working sessions were conducted at 4-week intervals with three healthcare professionals (HCP; physician, nurse, physiotherapist), eight patients, and two researchers (sociologist, public health pharmacist). The two initial focus group sessions were dedicated to the collection of narratives about CF treatment experiences to identify drivers of adherence. The next four working sessions were dedicated to the reflection on solutions that could alleviate the difficulties identified and be used in current clinical practice. The researchers observed during all sessions the interactions between participants, group dynamics, and process of implementation of the collective reflection. Results The process facilitated an active participation of patients and HCP, who contributed equally to the intervention development. The co-design adherence-enhancing intervention toolkit consisted in a self-questionnaire to be completed by patients before the medical consultation and used as a communication support during the consultation, plus a toolkit of solutions to be proposed by the HCP for each barrier identified by patients, and to be followed up during the next consultation. Conclusion This study demonstrated that a participatory approach involving CF patients and HCP lead to the development of an adherence-enhancing intervention toolkit, using a 6-session format; the benefits of the co-designed intervention on the medication adherence have yet to be tested in a multicenter, open-label study in 3 centers in France.
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Affiliation(s)
- Marie Viprey
- Hospices Civils de Lyon, Pôle Santé Publique, Service des Données de Santé, Lyon, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Correspondence: Marie Viprey, Hospices Civils de Lyon, Service des Données de Santé, 162 Avenue Lacassagne, Lyon, 69003, France, Tel +33 4 72 11 51 39, Fax +33 4 72 11 57 20, Email
| | | | - Alexandra Lelia Dima
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Parc Sanitari Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Julie Haesebaert
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Lyon, France
| | - Pauline Occelli
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Lyon, France
| | - Isabelle Durieu
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Centre de Référence Adulte de la Mucoviscidose, Pierre Bénite, France
| | - Héloïse Rouzé
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service Recherche et Epidémiologie Cliniques, Lyon, France
| | - Quitterie Reynaud
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Centre de Référence Adulte de la Mucoviscidose, Pierre Bénite, France
| | - Sandrine Touzet
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Santé au Travail, Lyon, France
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Cameron RA, Office D, Matthews J, Rowley M, Abbott J, Simmonds NJ, Whitty JA, Carr SB. Treatment Preference Among People With Cystic Fibrosis: The Importance of Reducing Treatment Burden. Chest 2022; 162:1241-1254. [PMID: 35868349 PMCID: PMC9773229 DOI: 10.1016/j.chest.2022.07.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/06/2022] [Accepted: 07/09/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND There is a growing consensus that the perspective of the patient should be considered in the evaluation of novel interventions. RESEARCH QUESTION What treatment outcomes matter to people with cystic fibrosis (CF), and what trade-offs would they make to realize these outcomes? STUDY DESIGN AND METHODS Adults attending a specialist CF center were invited to complete an online discrete choice experiment (DCE). The DCE required participants to evaluate hypothetical CF treatment profiles, defined by impact on lung function, pulmonary exacerbations, abdominal symptoms, life expectancy, quality of life, inhaled medicine usage, and physiotherapy requirement. Choice data were analyzed, using multinomial logit and latent class models. RESULTS One hundred and three people with CF completed the survey (median age, 35 years; range, 18-76 years); 52% were female; mean FEV1 % predicted, 69% [SD, 22%]). On average, an improvement in life expectancy by 10 years or more had the greatest impact on treatment preference, followed by a 15% increase in lung function. However, it was shown that people would trade substantial reductions in these key outcomes to reduce treatment time or burden. Preference profiles were not uniform across the sample: three distinct subgroups were identified, each placing markedly different importance on the relative importance of both life expectancy and lung function compared with other attributes. INTERPRETATION The relative importance of treatment burden to people with CF, compared with life expectancy and lung function, suggests it should be routinely captured in clinical trials as an important secondary outcome measure. When considering the patient perspective, it is important that decision-makers recognize that the values of people with CF are not homogeneous.
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Affiliation(s)
- Rory A Cameron
- Norwich Medical School, University of East Anglia, Norwich, England; National Institute for Health Research, Applied Research Collaboration, East of England, Cambridge, England.
| | - Daniel Office
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, England
| | - Jessie Matthews
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, England
| | | | - Janice Abbott
- School of Psychology, University of Central Lancashire, Preston, England
| | - Nicholas J Simmonds
- Adult Cystic Fibrosis Centre, Royal Brompton Hospital, London, England; National Heart and Lung Institute, Imperial College, London, England
| | - Jennifer A Whitty
- Norwich Medical School, University of East Anglia, Norwich, England; National Institute for Health Research, Applied Research Collaboration, East of England, Cambridge, England; Evidera, London, England
| | - Siobhán B Carr
- National Heart and Lung Institute, Imperial College, London, England; Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, England
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7
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Borowitz D, Brooks JF, Aliaj E, Gallotto D. Community Perspective on Pancreatic Enzyme Replacement Therapy in Cystic Fibrosis. J Pediatr Gastroenterol Nutr 2022; 75:e94-e97. [PMID: 36070542 DOI: 10.1097/mpg.0000000000003606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
People with cystic fibrosis (CF) and exocrine pancreatic insufficiency must take pancreatic enzyme replacement therapy (PERT) to prevent malnutrition and gastrointestinal (GI) symptoms. Finding better ways to manage GI complaints is a high priority for the CF community. We fielded a survey to assess the perspective of people affected by CF regarding symptoms attributed to and challenges associated with current PERT, to identify factors that affect participation in PERT studies, and to understand attitudes toward an outcome measure that could be an alternative to the coefficient of fat absorption test. Persistent GI symptoms are commonly ascribed to PERT. Minimizing time commitment and maximizing patient safety were factors affecting participation in research. We demonstrate 4 generalizable ways to incorporate patient experience early in the research process to aid in development of new medications and help improve study enrollment.
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Affiliation(s)
- Drucy Borowitz
- From the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | | | - Enid Aliaj
- the Cystic Fibrosis Foundation, Bethesda, MD
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8
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Abstract
Over the past decade there have been significant developments in the field of Cystic Fibrosis Transmembrane Regulator modulator drugs. Following treatment in patients with cystic fibrosis with common gating mutations using the potentiator drug ivacaftor, successive development of corrector drugs used in combination has led to highly effective modulator therapy being available to more than 85% of the cystic fibrosis population over 12 years of age in the form of elexacaftor/tezacaftor/ivacaftor. In this article, we review the evidence from clinical trials and mounting real-world observational and registry data that demonstrates the impact highly effective modulators have on both pulmonary and extra-pulmonary manifestations of cystic fibrosis. As clinical trials progress to younger patient groups, we discuss the challenges to demonstrating drug efficacy in early life, and also consider practicalities of drug development in an ever-shrinking modulator-naïve population. Drug-drug interactions are an important consideration in people with cystic fibrosis, where polypharmacy is commonplace, but also as the modulated population look to remain healthier for longer, we identify trials that aim to address treatment burden too. Inequity of care, through drug cost or ineligibility for modulators by genotype, is widening without apparent strategies to address this; however, we present evidence of hopeful early-stage drug development for non-modulatable genes and summarise the current state of gene-therapy development.
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Singh J, Towns S, Jayasuriya G, Hunt S, Simonds S, Boyton C, Middleton A, Kench A, Pandit C, Keatley LR, Chien J, Bishop J, Song Y, Robinson P, Selvadurai H, Middleton PG, Fitzgerald DA. Transition to adult care in cystic fibrosis: The challenges and the structure. Paediatr Respir Rev 2022; 41:23-29. [PMID: 32917516 DOI: 10.1016/j.prrv.2020.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/28/2020] [Indexed: 11/29/2022]
Abstract
In developed countries, it is projected that there will be a 70% increase in the number of adults living with Cystic Fibrosis (CF) between 2010 and 2025. This shift in demographics highlights the importance of high-quality transition programmes with developmentally appropriate integrated health care services as the individual moves through adolescence to adulthood. Adolescents living with CF face additional and unique challenges that may have long-term impacts on their health, quality of life and life-expectancy. CF specific issues around socially challenging symptoms, body image, reproductive health and treatment burden differentiate people with CF from their peers and require clinicians to identify and address these issues during the transition process. This review provides an overview of the health, developmental and psychosocial challenges faced by individuals with CF, their guardians and health care teams considering the fundamental components and tools that are required to build a transition programme that can be tailored to suit individual CF clinics.
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Affiliation(s)
- Jagdev Singh
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - Susan Towns
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Adolescent Medicine, Sydney Children's Hospital Network, Australia
| | - Geshani Jayasuriya
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; The Woolcock Institute of Medical Research, Sydney, NSW, Australia; Department of Adolescent Medicine, Sydney Children's Hospital Network, Australia
| | - Sharon Hunt
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Sharon Simonds
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Christie Boyton
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Anna Middleton
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Andrea Kench
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Chetan Pandit
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; The Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Lucy R Keatley
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, NSW, Australia
| | - Jimmy Chien
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, NSW, Australia
| | - Jennifer Bishop
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, NSW, Australia
| | - Yang Song
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, NSW, Australia; Westmead Clinical School, University of Sydney, NSW, Australia
| | - Paul Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; The Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Hiran Selvadurai
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Peter G Middleton
- Department of Adolescent Medicine, Sydney Children's Hospital Network, Australia; Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, Sydney, NSW, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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10
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Rowbotham NJ, Daniels TE. Airway clearance and exercise for people with cystic fibrosis: Balancing longevity with life. Pediatr Pulmonol 2022; 57 Suppl 1:S50-S59. [PMID: 34672434 DOI: 10.1002/ppul.25734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/01/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
Airway clearance has been an integral part of cystic fibrosis (CF) care for almost as long as CF has been identified as a condition. From diagnosis as a neonate through to end-of-life care, airway clearance is an everyday aspect of life, adding a considerable treatment burden to the lives of people with CF. There are many different techniques used for airway clearance which have evolved over time with an aim to improve effectiveness, support adherence and, more recently, to consider the impact of burden. A popular thought is whether airway clearance could be replaced by exercise. With new precision therapies in the form of CFTR modulators available, the CF landscape is rapidly changing, raising the question of whether certain treatments are needed at all. Depending on factors such as CFTR mutation, age, and pre-existing lung damage before starting a CFTR modulator, individuals with CF may need different levels of intensity and type of maintenance treatment. Precision medicine is likely to lead to the need for increased precision and individualized management around other maintenance therapies such as airway clearance.
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Affiliation(s)
- Nicola J Rowbotham
- Evidence Based Child Health Group, University of Nottingham, Nottingham, UK
| | - Tracey E Daniels
- York Hull Adult Cystic Fibrosis Centre, York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK.,School of Science, Technology and Health, York St John University, York, UK
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Virgin FW, Thurm C, Sanders DB, Freeman AJ, Cogen J, Gamel B, Sawicki G, Fink AK. Prevalence, variability, and predictors of sinus surgery in pediatric patients with cystic fibrosis. Pediatr Pulmonol 2021; 56:4029-4038. [PMID: 34648689 DOI: 10.1002/ppul.25669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 08/21/2021] [Accepted: 09/04/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Chronic rhinosinusitis is common among individuals with cystic fibrosis (CF) and has an impact on quality of life. Sinus surgery is a treatment option, but minimal literature exists regarding prevalence and indications. METHODS Using the linked CF Foundation Patient Registry (CFFPR) - Pediatric Health Information Systems (PHIS) database, we investigated variability in receipt of surgery, predictors of surgery, and time to first surgery. We included individuals less than 18 receiving care between 2006 and 2015 at a CF Foundation care program that is also a PHIS-participating-hospital. We used logistic regression to examine predictors of receipt of surgery and a Kaplan-Meier curve to examine time to first surgery among those born 2005-2007. RESULTS There were 11,545 children and adolescents and 2156 (18.7%) received at least one surgery. Variation in number of surgeries was observed across hospitals (median: 63 [IQR, 33-110]). There was an inconsistent pattern between receipt of surgery and markers of disease severity; those receiving surgery having increased odds of treatment use and pulmonary exacerbations and decreased odds of lower lung function and body mass index. Among the cohort of young children, 159 (14%) had at least one surgery with a median age at first surgery of 5.6 (IQR, 3.9-7.0). CONCLUSIONS The use of sinus surgery is frequent, but variable, among children and adolescents. Clinical factors are associated with receipt of surgery, but further understanding is needed on other factors that impact variability in use. Our study indicates the need for additional evaluation of the management of CF-related CRS and indications for surgery.
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Affiliation(s)
- Frank W Virgin
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Don B Sanders
- Pediatric Pulmonology, Indiana University, Indianapolis, Indiana, USA
| | - Alvin J Freeman
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan Cogen
- Department of Pulmonary Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Breck Gamel
- Children's Medical Center, Dallas, Texas, USA
| | - Greg Sawicki
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Aliza K Fink
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
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Langton Hewer SC, Smyth AR, Brown M, Jones AP, Hickey H, Kenna D, Ashby D, Thompson A, Sutton L, Clayton D, Arch B, Tanajewski Ł, Berdunov V, Williamson PR. Intravenous or oral antibiotic treatment in adults and children with cystic fibrosis and Pseudomonas aeruginosa infection: the TORPEDO-CF RCT. Health Technol Assess 2021; 25:1-128. [PMID: 34806975 DOI: 10.3310/hta25650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND People with cystic fibrosis are susceptible to pulmonary infection with Pseudomonas aeruginosa. This may become chronic and lead to increased mortality and morbidity. If treatment is commenced promptly, infection may be eradicated through prolonged antibiotic treatment. OBJECTIVE To compare the clinical effectiveness, cost-effectiveness and safety of two eradication regimens. DESIGN This was a Phase IV, multicentre, parallel-group, randomised controlled trial. SETTING Seventy UK and two Italian cystic fibrosis centres. PARTICIPANTS Participants were individuals with cystic fibrosis aged > 28 days old who had never had a P. aeruginosa infection or who had been infection free for 1 year. INTERVENTIONS Fourteen days of intravenous ceftazidime and tobramycin or 3 months of oral ciprofloxacin. Inhaled colistimethate sodium was included in both regimens over 3 months. Consenting patients were randomly allocated to either treatment arm in a 1 : 1 ratio using simple block randomisation with random variable block length. MAIN OUTCOME MEASURES The primary outcome was eradication of P. aeruginosa at 3 months and remaining free of infection to 15 months. Secondary outcomes included time to reoccurrence, spirometry, anthropometrics, pulmonary exacerbations and hospitalisations. Primary analysis used intention to treat (powered for superiority). Safety analysis included patients who had received at least one dose of any of the study drugs. Cost-effectiveness analysis explored the cost per successful eradication and the cost per quality-adjusted life-year. RESULTS Between 5 October 2010 and 27 January 2017, 286 patients were randomised: 137 patients to intravenous antibiotics and 149 patients to oral antibiotics. The numbers of participants achieving the primary outcome were 55 out of 125 (44%) in the intravenous group and 68 out of 130 (52%) in the oral group. Participants randomised to the intravenous group were less likely to achieve the primary outcome; although the difference between groups was not statistically significant, the clinically important difference that the trial aimed to detect was not contained within the confidence interval (relative risk 0.84, 95% confidence interval 0.65 to 1.09; p = 0.184). Significantly fewer patients in the intravenous group (40/129, 31%) than in the oral group (61/136, 44.9%) were hospitalised in the 12 months following eradication treatment (relative risk 0.69, 95% confidence interval 0.5 to 0.95; p = 0.02). There were no clinically important differences in other secondary outcomes. There were 32 serious adverse events in 24 participants [intravenous: 10/126 (7.9%); oral: 14/146 (9.6%)]. Oral therapy led to reductions in costs compared with intravenous therapy (-£5938.50, 95% confidence interval -£7190.30 to -£4686.70). Intravenous therapy usually necessitated hospital admission, which accounted for a large part of this cost. LIMITATIONS Only 15 out of the 286 participants recruited were adults - partly because of the smaller number of adult centres participating in the trial. The possibility that the trial participants may be different from the rest of the cystic fibrosis population and may have had a better clinical status, and so be more likely to agree to the uncertainty of trial participation, cannot be ruled out. CONCLUSIONS Intravenous antibiotics did not achieve sustained eradication of P. aeruginosa in a greater proportion of cystic fibrosis patients. Although there were fewer hospitalisations in the intravenous group during follow-up, this confers no advantage over the oral therapy group, as intravenous eradication frequently requires hospitalisation. These results do not support the use of intravenous antibiotics to eradicate P. aeruginosa in cystic fibrosis. FUTURE WORK Future research studies should combine long-term follow-up with regimens to reduce reoccurrence after eradication. TRIAL REGISTRATION Current Controlled Trials ISRCTN02734162 and EudraCT 2009-012575-10. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 65. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon C Langton Hewer
- Department of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children.,University of Bristol, Bristol, UK
| | - Alan R Smyth
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Michaela Brown
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Ashley P Jones
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Helen Hickey
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Dervla Kenna
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, London, UK
| | - Alexander Thompson
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
| | - Laura Sutton
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Dannii Clayton
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Barbara Arch
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
| | - Łukasz Tanajewski
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Vladislav Berdunov
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Paula R Williamson
- Liverpool Clinical Trials Centre, University of Liverpool, a member of the Liverpool Health Partners, Liverpool, UK
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Sharma PB, Sathe M, Savant AP. Year in Review 2020: Multisystemic impact of cystic fibrosis. Pediatr Pulmonol 2021; 56:3110-3119. [PMID: 34324789 DOI: 10.1002/ppul.25584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 12/13/2022]
Abstract
Clinical care in cystic fibrosis (CF) has continued to advance over the last several years, particularly with the widespread eligibility and use of highly effective modulator therapy. Improved outcomes and longevity of persons with CF (PwCF) have increased recognition of the multisystem impact of the disease on the daily lives of PwCF. This review will cover a broad array of topics, from diagnosis to multisystem effects related to mental health, endocrine, palliative care, reproductive health, otolaryngology, and cardiac issues. Additionally, worldwide care delivery will be reviewed, demonstrating variation in outcomes based on resources and populations served. This review is part of the CF Year in Review 2020 series, focusing on the multi-system effects of CF. This review focuses on articles from Pediatric Pulmonology but also includes articles published in 2020 from other journals that are of particular interest to clinicians.
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Affiliation(s)
- Preeti B Sharma
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Texas Southwestern and Children's Health, Dallas, Texas, USA
| | - Meghana Sathe
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern and Children's Health, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Adrienne P Savant
- Department of Pediatrics, Division of Pulmonary Medicine, Tulane University School of Medicine, Children's Hospital of New Orleans, New Orleans, Louisiana, USA
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14
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Bevan A, Hoo ZH, Totton N, Girling C, Davids IR, Whelan P, Antrobus S, Ainsworth J, Buchan I, Anderson A, Bourke S, Doe S, Echevarria C, Taylor J, Bell NJ, Bateman K, Jones C, Moran P, Fitch G, Martin M, McGowan A, Morrow S, Seabridge H, Bush N, Daniels T, Lee K, Robson N, Shiferaw D, Sweis D, Thomas R, Faulkner J, Flight WG, Poole S, Warnock L, Allenby MI, Carroll M, Daniels TV, Dunn H, Nightingale JA, Shepherd E, Ohri C, Gadsby J, Range S, Tature D, Barr HL, Dawson S, Dewar J, Miller B, Saini G, Galey P, Johnson J, Pasteur MC, Derry D, Gledhill H, Lawson A, Thomas M, Waine D, Cunningham J, Damani A, Higton A, Orchard C, Carolan C, Tahir M, Plummer A, Hutchings M, Edenborough FP, Curley R, Wildman MJ. Using a learning health system to understand the mismatch between medicines supply and actual medicines use among adults with cystic fibrosis. J Cyst Fibros 2021; 21:323-331. [PMID: 34565705 DOI: 10.1016/j.jcf.2021.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 09/01/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Studies in separate cohorts suggest possible discrepancies between inhaled medicines supplied (median 50-60%) and medicines used (median 30-40%). We performed the first study that directly compares CF medicine supply against use to identify the cost of excess medicines supply. METHODS This cross-sectional study included participants from 12 UK adult centres with ≥1 year of continuous adherence data from data-logging nebulisers. Medicine supply was measured as medication possession ratio (MPR) for a 1-year period from the first suitable supply date. Medicine use was measured as electronic data capture (EDC) adherence over the same period. The cost of excess medicines was calculated as whole excess box(es) supplied after accounting for the discrepancy between EDC adherence and MPR with 20% contingency. RESULTS Among 275 participants, 133 (48.4%) were females and mean age was 30 years (95% CI 29-31 years). Median EDC adherence was 57% (IQR 23-86%), median MPR was 74% (IQR 46-96%) and the discrepancy between measures was median 14% (IQR 2-29%). Even with 20% contingency, mean potential cost of excess medicines was £1,124 (95% CI £855-1,394), ranging from £183 (95% CI £29-338) for EDC adherence ≥80% to £2,017 (95% CI £1,507-2,526) for EDC adherence <50%. CONCLUSIONS This study provides a conservative estimate of excess inhaled medicines supply cost among adults with CF in the UK. The excess supply cost was highest among those with lowest EDC adherence, highlighting the importance of adherence support and supplying medicine according to actual use. MPR provides information about medicine supply but over-estimates actual medicine use.
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Affiliation(s)
- Amanda Bevan
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Zhe Hui Hoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nikki Totton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Carla Girling
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - India R Davids
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Pauline Whelan
- Centre for Health Informatics, University of Manchester, Manchester, UK
| | - Steven Antrobus
- Centre for Health Informatics, University of Manchester, Manchester, UK
| | - John Ainsworth
- Centre for Health Informatics, University of Manchester, Manchester, UK
| | - Iain Buchan
- Centre for Health Informatics, University of Manchester, Manchester, UK
| | - Alan Anderson
- Newcastle Adult Cystic Fibrosis Centre, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stephen Bourke
- Newcastle Adult Cystic Fibrosis Centre, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Simon Doe
- Newcastle Adult Cystic Fibrosis Centre, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Carlos Echevarria
- Newcastle Adult Cystic Fibrosis Centre, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jill Taylor
- Newcastle Adult Cystic Fibrosis Centre, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nicholas J Bell
- Bristol Adult Cystic Fibrosis Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kathryn Bateman
- Bristol Adult Cystic Fibrosis Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Carys Jones
- Bristol Adult Cystic Fibrosis Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Peter Moran
- Bristol Adult Cystic Fibrosis Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Giles Fitch
- North West Midlands Cystic Fibrosis Centre, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Michael Martin
- North West Midlands Cystic Fibrosis Centre, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Angela McGowan
- North West Midlands Cystic Fibrosis Centre, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Stephen Morrow
- North West Midlands Cystic Fibrosis Centre, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Heather Seabridge
- North West Midlands Cystic Fibrosis Centre, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Nicki Bush
- York Hull Adult Cystic Fibrosis Centre, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Tracey Daniels
- York Hull Adult Cystic Fibrosis Centre, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Katy Lee
- York Hull Adult Cystic Fibrosis Centre, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Nicola Robson
- York Hull Adult Cystic Fibrosis Centre, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Dejene Shiferaw
- York Hull Adult Cystic Fibrosis Centre, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Dimah Sweis
- York Hull Adult Cystic Fibrosis Centre, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Rebecca Thomas
- York Hull Adult Cystic Fibrosis Centre, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Jayne Faulkner
- Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - William G Flight
- Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah Poole
- Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Louise Warnock
- Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mark I Allenby
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mary Carroll
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Respiratory Biomedical Research Centre, University of Southampton, Southampton, UK
| | - Thomas V Daniels
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Respiratory Biomedical Research Centre, University of Southampton, Southampton, UK
| | - Helen Dunn
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Julia A Nightingale
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Elizabeth Shepherd
- Wessex Adult Cystic Fibrosis Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chandra Ohri
- Leicester Adult Cystic Fibrosis Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jessica Gadsby
- Leicester Adult Cystic Fibrosis Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Simon Range
- Leicester Adult Cystic Fibrosis Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Darren Tature
- Leicester Adult Cystic Fibrosis Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Helen L Barr
- Wolfson Adult Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sophie Dawson
- Wolfson Adult Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jane Dewar
- Wolfson Adult Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Bryony Miller
- Wolfson Adult Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Gauri Saini
- Wolfson Adult Cystic Fibrosis Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Penny Galey
- Adult Cystic Fibrosis Clinic, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Jack Johnson
- Adult Cystic Fibrosis Clinic, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Mark C Pasteur
- Adult Cystic Fibrosis Clinic, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - David Derry
- Derriford Hospital Adult Cystic Fibrosis Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Harriet Gledhill
- Derriford Hospital Adult Cystic Fibrosis Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Angharad Lawson
- Derriford Hospital Adult Cystic Fibrosis Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Michelle Thomas
- Derriford Hospital Adult Cystic Fibrosis Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - David Waine
- Derriford Hospital Adult Cystic Fibrosis Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Josie Cunningham
- Cystic Fibrosis Unit, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Annant Damani
- Cystic Fibrosis Unit, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Alexandra Higton
- Cystic Fibrosis Unit, Frimley Health NHS Foundation Trust, Frimley, UK
| | | | - Charlotte Carolan
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Misbah Tahir
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Amanda Plummer
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Marlene Hutchings
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Frank P Edenborough
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachael Curley
- Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Martin J Wildman
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; Sheffield Adult Cystic Fibrosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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15
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Sathe M, Moshiree B, Vu PT, Khan U, Heltshe SL, Romasco M, Freedman SD, Schwarzenberg SJ, Goss CH, Freeman AJ. Utilization of electronic patient-reported outcome measures in cystic fibrosis research: Application to the GALAXY study. J Cyst Fibros 2021; 20:605-611. [PMID: 34305007 DOI: 10.1016/j.jcf.2021.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 06/30/2021] [Accepted: 07/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Food and Drug Administration considers patient-reported outcome measures (PROMs) an essential part of clinical research studies for approval of new drugs and new indications for existing drugs. GALAXY evaluated the feasibility of electronic PROMs (ePROMS) to conduct a comprehensive evaluation of gastrointestinal (GI) symptoms in persons with cystic fibrosis (pwCF). METHODS Three validated GI ePROMs (PAC-SYM, PAGI-SYM and PAC-QOL) were combined with a Stool-Specific questionnaire to make up the GALAXY ePROMs and administered prospectively across 26 CF centers in the United States. The ePROMs were completed at enrollment visit and then electronically at weeks 1, 2 and 4. PwCF at least 2 years and older were eligible for the study. Reminders were only provided by the mobile application during the study window. RESULTS There were 402 participants enrolled in GALAXY. Of those, 169 (42%) were under 18 years old and 193 (48%) were female. The proportion of all follow-up weeks with at least 1 ePROM fully completed was 80%, slightly higher in those ≥18 years of age (82.5%) compared to those <18 years of age (76.5%). When assessing the completion for all 4 ePROMs, the percentage was 77.6%, also higher among those ≥18 year of age (81.5% versus 72.2% for < 18 years of age). CONCLUSION Using ePROMs, our study demonstrated that GI symptoms can be feasibly collected with good reproducibility and with minimal involvement of research coordinator time. This mechanism of symptom collection may provide an efficient tool for future CF trials.
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Affiliation(s)
- Meghana Sathe
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern/Children's Health, Dallas, TX.
| | - Baha Moshiree
- Division of Gastroenterology, Atrium Health, Charlotte, NC
| | - Phuong T Vu
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Umer Khan
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Sonya L Heltshe
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Melita Romasco
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA
| | - Steven D Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Christopher H Goss
- Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - A Jay Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
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16
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Sanz JH, Anixt J, Bear L, Basken A, Beca J, Marino BS, Mussatto KA, Nembhard WN, Sadhwani A, Sananes R, Shekerdemian LS, Sood E, Uzark K, Willen E, Ilardi D. Characterisation of neurodevelopmental and psychological outcomes in CHD: a research agenda and recommendations from the cardiac neurodevelopmental outcome collaborative. Cardiol Young 2021; 31:876-887. [PMID: 34082845 PMCID: PMC8429101 DOI: 10.1017/s1047951121002146] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The Neurodevelopmental and Psychological Outcomes Working Group of the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute with the goals of identifying knowledge gaps regarding the neurodevelopmental and psychological outcomes of individuals with CHD and investigations needed to advance science, policy, clinical care, and patient/family outcomes. Accurate characterisation of neurodevelopmental and psychological outcomes in children with CHD will drive improvements in patient and family outcomes through targeted intervention. Decades of research have produced a generalised perspective about neurodevelopmental and psychological outcomes in this heterogeneous population. Future investigations need to shift towards improving methods, measurement, and analyses of outcomes to better inform early identification, prevention, and intervention. Improved definition of underlying developmental, neuropsychological, and social-emotional constructs is needed, with an emphasis on symptom networks and dimensions. Identification of clinically meaningful outcomes that are most important to key stakeholders, including patients, families, schools and providers, is essential, specifically how and which neurodevelopmental differences across the developmental trajectory impact stakeholders. A better understanding of the discontinuity and patterns of neurodevelopment across the lifespan is critical as well, with some areas being more impactful at some ages than others. Finally, the field needs to account for the impact of race/ethnicity, socio-economic status, cultural and linguistic diversity on our measurement, interpretation of data, and approach to intervention and how to improve generalisability to the larger worldwide population of patients and families living with CHD.
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Affiliation(s)
- Jacqueline H. Sanz
- Division of Neuropsychology, Children’s National Hospital, Departments of Psychiatry and Behavioral Sciences & Pediatrics, George Washington University School of Medicine, Washington, DC, USA
| | - Julia Anixt
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Laurel Bear
- Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children’s Wisconsin, Milwaukee, Wisconsin, USA
| | | | - John Beca
- Department of Intensive Care, Starship Children’s Health, Auckland, New Zealand
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children’s Hospital, Cleveland, Ohio, USA
| | | | - Wendy N. Nembhard
- Department of Epidemiology and the Arkansas Birth Defects Center for Research and Prevention, Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Anjali Sadhwani
- Department of Psychiatry, Boston Children’s Hospital & Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Renee Sananes
- Division of Cardiology, Department of Psychology, The Hospital for Sick Children, Department of Pediatrics, The University of Toronto, Toronto, Canada
| | - Lara S. Shekerdemian
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Houston, TX, USA
| | - Erica Sood
- Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, DE & Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Karen Uzark
- Department of Pediatrics, Section of Pediatric Cardiology, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Elizabeth Willen
- Division of Developmental and Behavioral Sciences and the Ward Family Heart Center, Children’s Mercy, Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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Freeman AJ, Sathe M, Aliaj E, Borowitz D, Fogarty B, Goss CH, Freedman S, Heltshe SL, Khan U, Riva D, Roman C, Romasco M, Schwarzenberg SJ, Ufret-Vincenty CA, Moshiree B. Designing the GALAXY study: Partnering with the cystic fibrosis community to optimize assessment of gastrointestinal symptoms. J Cyst Fibros 2021; 20:598-604. [PMID: 33451899 DOI: 10.1016/j.jcf.2020.12.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastrointestinal (GI) involvement among persons with cystic fibrosis (CF) is highly prevalent, representing a significant source of morbidity. Persons with CF have identified GI concerns as a top research priority, yet universal clinical outcome measures capturing many of the GI symptoms experienced in CF are lacking. The GALAXY study was envisioned to address this unmet need. METHODS The GALAXY study team partnered with Community Voice, a community of patients with CF and their caregivers, to identify the patient reported outcome measures that most accurately reflected their experience with GI symptoms in CF. We also surveyed CF care teams to identify the comfort level of various team members (providers, nurses and dieticians) in managing a variety of GI conditions. RESULTS Members of Community Voice identified the combination of PAC-SYM, PAGI-SYM, PAC-QOL and the Bristol Stool scale with three additional symptom-specific questions as patient-reported outcome measures that comprehensively captured the CF experience with GI disease. CF care team providers reported a high level of comfort in treating GI conditions including constipation (92%), GERD (93%), and gassiness (77%), however comfort level was limited to only first-line interventions. CONCLUSION By partnering with persons with CF as well as their caregivers and medical providers, the GALAXY study is designed to uniquely capture the prevalence and severity of GI involvement among persons with CF in a manner that reflects the CF patient experience. The results of GALAXY will inform the development of future interventional trials and serve as a reproducible and objective study endpoint.
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Affiliation(s)
- A Jay Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA.
| | - Meghana Sathe
- Division of Gastroenterology, Hepatology and Nutrition, Children's Health University of Texas Southwestern, Dallas, TX, USA
| | - Enid Aliaj
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | - Drucy Borowitz
- Cystic Fibrosis Foundation, Bethesda, MD, USA; Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Barbra Fogarty
- Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Christopher H Goss
- Seattle Children's Hospital Research Institute, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Steven Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sonya L Heltshe
- Seattle Children's Hospital Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Umer Khan
- Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | - Dara Riva
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | | | - Melita Romasco
- Seattle Children's Hospital Research Institute, Seattle, WA, USA
| | | | | | - Baha Moshiree
- University of North Carolina, Atrium Health, Charlotte, NC, USA
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18
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Groot B, Dedding C, Slob E, Maitland H, Teunissen T, Rutjes N, Vijverberg S. Adolescents' experiences with patient engagement in respiratory medicine. Pediatr Pulmonol 2021; 56:211-216. [PMID: 33124758 PMCID: PMC7756216 DOI: 10.1002/ppul.25150] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/16/2020] [Accepted: 10/24/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Adolescent engagement in decision-making processes in health care and research in the field of chronic respiratory diseases is rare but increasingly recognized as important. The aim of this study was to reflect on adolescents' motives and experiences in the process of establishing an advisory council for adolescents with a chronic respiratory disease. METHODS A qualitative evaluation study was undertaken to assess the process of starting an advisory youth council in a tertiary hospital in the Netherlands. Data collection consisted of observations of council meetings, in-depth interviews with youth council members, and moderated group discussions. Data were analyzed using thematic analysis to explore the experiences of the council members (n = 9, aged 12-18 years, all with a chronic respiratory disease). Two-hour council meetings took place in the hospital to provide solicited and unsolicited advice to improve research and care. RESULTS Three themes were identified as motives for adolescents to engage in an advisory council: (1) experience of fun and becoming empowered by their illness; (2) the value of peer support and contact; and (3) being able to contribute to care and research. The council's output consisted of solicited advice on information leaflets for patients, study procedures, and dietary menu options for hospitalized children. The council struggled to have their unsolicited advice heard within the hospital. CONCLUSIONS Council members experienced engagement as beneficial at the individual, group, and organizational levels. However, meaningful youth engagement requires connectedness with, and official support from, officials at all levels within an organization.
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Affiliation(s)
- Barbara Groot
- Department of Ethics, Law, and Humanities, Amsterdam Public Health Institute, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Christine Dedding
- Department of Ethics, Law, and Humanities, Amsterdam Public Health Institute, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Elise Slob
- Department of Respiratory Medicine, Amsterdam Public Health Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Pediatric Pulmonology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henriette Maitland
- Department of Respiratory Medicine, Amsterdam Public Health Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Truus Teunissen
- Department of Ethics, Law, and Humanities, Amsterdam Public Health Institute, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Niels Rutjes
- Department of Pediatric Pulmonology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Susanne Vijverberg
- Department of Respiratory Medicine, Amsterdam Public Health Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Pediatric Pulmonology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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19
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Hewer SCL, Smyth AR, Brown M, Jones AP, Hickey H, Kenna D, Ashby D, Thompson A, Williamson PR. Intravenous versus oral antibiotics for eradication of Pseudomonas aeruginosa in cystic fibrosis (TORPEDO-CF): a randomised controlled trial. Lancet Respir Med 2020; 8:975-986. [PMID: 33007285 PMCID: PMC7606906 DOI: 10.1016/s2213-2600(20)30331-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 05/05/2020] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Chronic pulmonary infection with Pseudomonas aeruginosa is one of the most important causes of mortality and morbidity in cystic fibrosis. If antibiotics are commenced promptly, infection can be eradicated. The aim of the trial was to compare the effectiveness and safety of intravenous ceftazidime and tobramycin versus oral ciprofloxacin in the eradication of P aeruginosa. METHODS We did a multicentre, parallel group, open-label, randomised controlled trial in 72 cystic fibrosis centres (70 in the UK and two in Italy). Eligible participants were older than 28 days with an isolate of P aeruginosa (either the first ever isolate or a new isolate after at least 1 year free of infection). Participants were excluded if the P aeruginosa was resistant to, or they had a contraindication to, one or more of the trial antibiotics; if they were already receiving P aeruginosa suppressive therapy; if they had received any P aeruginosa eradication therapy within the previous 9 months; or if they were pregnant or breastfeeding. We used web-based randomisation to assign patients to 14 days intravenous ceftazidime and tobramycin or 12 weeks oral ciprofloxacin. Both were combined with 12 weeks inhaled colistimethate sodium. Randomisation lists were generated by a statistician, who had no involvement in the trial, using a computer-generated list. Randomisation was stratified by centre and because of the nature of the interventions, blinding was not possible. Our primary outcome was eradication of P aeruginosa at 3 months and remaining free of infection to 15 months. Primary analysis used intention to treat (powered for superiority). Safety analysis included patients who received at least one dose of study drug. TORPEDO-CF was registered on the ISRCTN register, ISRCTN02734162, and EudraCT, 2009-012575-10. FINDINGS Between Oct 5, 2010, and Jan 27, 2017, 286 patients were randomly assigned to treatment: 137 to intravenous antibiotics and 149 to oral antibiotics. 55 (44%) of 125 participants in the intravenous group and 68 (52%) of 130 participants in the oral group achieved the primary outcome. Participants randomly assigned to the intravenous group were less likely to achieve the primary outcome, although the difference between groups was not statistically significant (relative risk 0·84, 95% CI 0·65-1·09; p=0·18). 11 serious adverse events occurred in ten (8%) of 126 participants in the intravenous antibiotics group and 17 serious adverse events in 12 (8%) of 146 participants in the oral antibiotics group. INTERPRETATION Compared with oral therapy, intravenous antibiotics did not achieve sustained eradication of P aeruginosa in a greater proportion of patients with cystic fibrosis and was more expensive. Although there were fewer hospitalisations in the intravenous group than the oral group during follow-up, this confers no advantage over oral treatment because intravenous eradication frequently requires hospitalisation. These results do not support the use of intravenous antibiotics to eradicate P aeruginosa in cystic fibrosis. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Simon C Langton Hewer
- Department of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, University of Bristol, Bristol, UK.
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Nottingham, UK
| | - Michaela Brown
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Ashley P Jones
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Helen Hickey
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Dervla Kenna
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, London, UK
| | - Alexander Thompson
- The University of Manchester, Manchester Centre for Health Economics, Manchester, UK
| | - Paula R Williamson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool Health Partners, Liverpool, UK
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20
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Hempstead SE, Fredkin K, Hovater C, Naureckas ET. Patient and Family Participation in Clinical Guidelines Development: The Cystic Fibrosis Foundation Experience. J Particip Med 2020; 12:e17875. [PMID: 33064090 PMCID: PMC7434055 DOI: 10.2196/17875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/30/2020] [Accepted: 05/06/2020] [Indexed: 01/14/2023] Open
Abstract
Patient and family participation in guideline development is neither standardized nor uniformly accepted in the guideline development community, despite the 2011 Institute of Medicine’s Guidelines We Can Trust and the Guideline International Network’s GIN-Public Toolkit recommendations. The Cystic Fibrosis Foundation has included patients and/or family members directly in guideline development since 2004. Over time, various strategies for increasing patient and family member participation have been implemented. Surveys of recent patient/family and clinical guidelines committee members have shown that inclusion of individuals with cystic fibrosis and their family members on guidelines committees has provided insight otherwise invisible to clinicians.
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Affiliation(s)
| | | | - Cade Hovater
- Community Advisor to the Cystic Fibrosis Foundation, Bethesda, MD, United States
| | - Edward T Naureckas
- Department of Pulmonary Medicine, University of Chicago, Chicago, IL, United States
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21
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Bullington W, Hempstead S, Smyth AR, Drevinek P, Saiman L, Waters VJ, Bell SC, VanDevanter DR, Flume PA, Elborn S, Muhlebach MS. Antimicrobial resistance: Concerns of healthcare providers and people with CF. J Cyst Fibros 2020; 20:407-412. [PMID: 32563724 DOI: 10.1016/j.jcf.2020.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic lung infections and their treatment pose risks for the development of antimicrobial resistance (AMR) in people with cystic fibrosis (PWCF). In this study, we evaluated the attitudes of healthcare providers' (HCP) and PWCF or their parents' toward AMR within the international CF community. METHODS HCP and PWCF identified through listservs and CF-related organizations were asked to complete an AMR centered survey, with additional questions on antimicrobial stewardship (AMS) for HCP. Descriptive analyses are reported. RESULTS The responding 443 HCP and 464 PWCF/Parents were from 30 and 25 countries, respectively. Sixty-two percent of HCP and 56% of PWCF stated they were "very concerned" about AMR, with Pseudomonas spp. and Burkholderia spp. considered the most concerning organisms for both HCP and PWCF/Parents. Non-tuberculous mycobacteria were of greater concern to HCP compared to PWCF/Parents. There was a discrepancy regarding AMR education to PWCF, with 80% of HCP stating having discussed this with PWCF/Parents, but only 50% of PWCF recalling such discussions. CONCLUSION These results highlight that AMR is relevant to CF HCP and PWCF internationally, indicating that educational tools and research are warranted.
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Affiliation(s)
- Wendy Bullington
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA.
| | | | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Nottingham, United Kingdom.
| | - Pavel Drevinek
- Departments of Medical Microbiology Motol University Hospital and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Lisa Saiman
- Department of Pediatrics, Columbia University, New York, New York, USA.
| | - Valerie J Waters
- Division of Infectious Diseases, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Scott C Bell
- Department of Thoracic Medicine, The Prince Charles Hospital and QIMR Berghofer Medical Research Institute, Brisbane, Australia.
| | - Donald R VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Patrick A Flume
- Departments of Medicine and Pediatrics, Medical University of South Carolina, Charleston, SC, USA.
| | - Stuart Elborn
- Imperial College and Royal Brompton Hospital, London and Queen's University Belfast, United Kingdom.
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Lanar S, Acquadro C, Seaton J, Savre I, Arnould B. To what degree are orphan drugs patient-centered? A review of the current state of clinical research in rare diseases. Orphanet J Rare Dis 2020; 15:134. [PMID: 32493385 PMCID: PMC7268539 DOI: 10.1186/s13023-020-01400-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Over the past 30 years, the healthcare industry has increasingly turned its attention to rare diseases. Regulators have emphasized the need for clinical research in this area to be patient-centered. However, there is a lack of evidence concerning whether this need is actually met. In this paper, we aim to address this gap. METHODS First, we describe the state of patient-centricity in clinical research in rare diseases based on a targeted literature review. Second, we discuss recommendations from scientific bodies on patient-reported outcome (PRO) measures in rare diseases. Third, we analyze data collected from EMA's and FDA's websites concerning rare disease labeling claims and data from Clinicaltrials.gov concerning the use of PRO measures in rare disease pivotal trials. Fourth, we perform an exhaustive literature review on the use of PRO measures in the pharmaceutical industry, including all phases of clinical research, observational/registry studies, and instrument development and validation. RESULTS There is limited information on rare disease patient engagement in study design, recruitment, and retention. None of the initiatives describing methods for developing PRO measures in rare diseases provide the clear guidance clinical researchers need. Only 17.4% of orphan drug labels contain a PRO measure. Less than half of pivotal trials in orphan drugs have a PRO measure as a primary or a secondary endpoint. Although the number of publications about PRO measures in rare diseases has risen in the past fifteen years, our results indicate that substantial improvements are needed to achieve patient-centricity. CONCLUSIONS The nature and extent of patient engagement in rare disease research is under-documented. The current paradigm for developing and using PRO measures in clinical research is failing to meet the needs of rare disease patients. Not only are PROs rarely used as high-level endpoints in clinical trials or taken into account in labeling claims, they are also under-researched overall - there are too few measures for the multitude of rare diseases. We call for a clear guidance on patient engagement and suggest a realistic approach to the adaptation of PRO strategy to the specific context of clinical research in rare diseases.
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Affiliation(s)
- Sally Lanar
- ICON plc, Patient-Centered Outcomes, 27 rue de la Villette, 69003 Lyon, France
| | - Catherine Acquadro
- ICON plc, Patient-Centered Outcomes, 27 rue de la Villette, 69003 Lyon, France
| | - James Seaton
- Seaton Associates, LLC, 9039 Sligo Creek Parkway #1408, Silver Spring, MD 20901 USA
| | - Isabelle Savre
- Mapi Research Trust, 27 rue de la Villette, 69003 Lyon, France
| | - Benoit Arnould
- ICON plc, Patient-Centered Outcomes, 27 rue de la Villette, 69003 Lyon, France
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Cooley L, Hudson J, Potter E, Raymond KF, George C, Georgiopoulos AM. Clinical communication preferences in cystic fibrosis and strategies to optimize care. Pediatr Pulmonol 2020; 55:948-958. [PMID: 31977168 DOI: 10.1002/ppul.24655] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 01/10/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The importance of optimizing communication between clinicians and individuals and families living with cystic fibrosis (CF) about daily care, adherence, and related psychosocial concerns is well documented. The purpose of this study was to gain an understanding of interpersonal communication experiences and preferences among individuals and families living with CF as they engage with the clinical team. The study also aimed to reveal opportunities for enhancing future interpersonal communication practices. METHODS Five U.S. CF care centers participated in the following activities: (a) On-site observation of clinic interactions during outpatient visits; (b) On-site 1:1 interviews with individuals living with CF, their family members, and CF clinicians; (d) Focus groups conducted in person with CF care team members; (d) Focus groups conducted virtually with adults and family members with CF. Content analysis of transcripts and constant comparative methods were used to identify emergent themes. RESULTS Four themes related to participants' needs and preferences for clinic interactions emerged during analysis: (a) eliciting psychosocial concerns, (b) addressing childhood development and transitions, (c) negotiating agendas and sharing decisions, and (d) educating to enhance CF conversations. CONCLUSION CF clinicians and individuals and families living with CF expressed the need for resources and training to engage in better conversations with each other. Participants identified areas of high priority, including working together around social, psychological, and economic challenges, preparation for transition to adulthood, and sustaining daily care. Findings point to the value of developing advanced communication skills that foster trust-building, negotiating agendas, active listening, and collaborative goal-setting.
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Affiliation(s)
- Laura Cooley
- Division of Education and Outreach, Academy of Communication in Healthcare, Lexington, Kentucky
| | - Janella Hudson
- Division of Education and Outreach, Academy of Communication in Healthcare, Lexington, Kentucky
| | - Eileen Potter
- Department of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Katherine F Raymond
- Partnerships for Sustaining Daily Care, The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Cynthia George
- Partnerships for Sustaining Daily Care, The Cystic Fibrosis Foundation, Bethesda, Maryland
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24
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Davies G, Rowbotham NJ, Smith S, Elliot ZC, Gathercole K, Rayner O, Leighton PA, Herbert S, Duff AJ, Chandran S, Daniels T, Nash EF, Smyth AR. Characterising burden of treatment in cystic fibrosis to identify priority areas for clinical trials. J Cyst Fibros 2019; 19:499-502. [PMID: 31735561 DOI: 10.1016/j.jcf.2019.10.025] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/26/2019] [Accepted: 10/29/2019] [Indexed: 11/24/2022]
Abstract
In a recent James Lind Alliance Priority Setting Partnership in cystic fibrosis (CF) the top priority clinical research question was: "What are effective ways of simplifying the treatment burden of people with CF?" We aimed to summarise the lived experience of treatment burden and suggest research themes aimed at reducing it. An online questionnaire was co-produced and responses subjected to quantitative and thematic analysis. 941 survey responses were received (641 from lay community). People with CF reported a median of 10 (interquartile range: 6-15) current treatments. Seven main themes relating to simplifying treatment burden were identified. Treatment burden is high, extending beyond time taken to perform routine daily treatments, with impact varying according to person-specific factors. Approaches to communication, support, evaluation of current treatments, service set-up, and treatment logistics (obtaining/administration) contribute to burden, offering scope for evaluation in clinical trials or service improvement.
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Affiliation(s)
- Gwyneth Davies
- Respiratory, Critical Care and Anaesthesia Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.
| | - Nicola J Rowbotham
- Evidence Based Child Health Group, University of Nottingham, Nottingham, United Kingdom
| | - Sherie Smith
- Evidence Based Child Health Group, University of Nottingham, Nottingham, United Kingdom
| | - Zoe C Elliot
- Parent of Children with CF, Nottingham, United Kingdom
| | - Katie Gathercole
- University of Leeds, Leeds, United Kingdom; Person with CF, Leeds, United Kingdom
| | - Oli Rayner
- Person with CF, Plymouth, United Kingdom
| | - Paul A Leighton
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Sophie Herbert
- Evidence Based Child Health Group, University of Nottingham, Nottingham, United Kingdom
| | | | - Suja Chandran
- Paediatric CF Service, Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | - Tracey Daniels
- Department of Physiotherapy, York Hull Adult CF Unit, York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | - Edward F Nash
- West Midlands Adult CF Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Alan R Smyth
- Evidence Based Child Health Group, University of Nottingham, Nottingham, United Kingdom
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26
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Solomon GM, Nichols DP. Taskforce recommends coordinated effort to improve clinical research conduct and find highly effective CFTR-directed treatment for rare mutations. J Cyst Fibros 2019; 18:579-580. [PMID: 31279576 DOI: 10.1016/j.jcf.2019.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- G M Solomon
- Department of Medicine, The Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL, USA..
| | - D P Nichols
- Department of Pediatrics, CF Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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