The success of the Cystic Fibrosis Registry of Turkey for improvement of patient care

BACKGROUND

Cystic fibrosis (CF) registries play an essential role in improving disease outcomes of people with CF. This study aimed to evaluate the association of newly established CF registry system in Turkey on follow-up, clinical, growth, treatment, and complications of people with this disease.

METHODS

Age at diagnosis, current age, sex, z-scores of weight, height and body mass index (BMI), neonatal screening results, pulmonary function tests, history of meconium ileus, medications, presence of microorganisms, and follow-up were evaluated and compared to data of people with CF represented in both 2017 and 2019 registry data.

RESULTS

There were 1170 people with CF in 2017 and 1637 in 2019 CF registry. Eight hundred and fourteen people were registered in both 2017 and 2019 of whom z-scores of heights and BMI were significantly higher in 2019 (p = 0.002, p =0.039, respectively). Inhaled hypertonic saline, bronchodilator, and azithromycin usages were significantly higher in 2019 (p =0.001, p = 0.001, p = 0.003, respectively). The percent predicted of forced expiratory volume in  1 sec and forced vital capacity were similar in 2017 and 2019 (88% and 89.5%, p = 0.248 and 84.5% and 87%, p =0.332, respectively). Liver diseases and osteoporosis were significantly higher, and pseudo-Bartter syndrome (PBS) was significantly lower in 2019 (p = 0.011, p = 0.001, p = 0.001, respectively).

CONCLUSIONS

The z-scores of height and BMI were higher, the use of medications that protect and improve lung functions was higher and incidence of PBS was lower in 2019. It was predicted that registry system increased the care of people with CF regarding their follow-up. The widespread use of national CF registry system across the country may be beneficial for the follow-up of people with CF.

Clinical findings of patients with cystic fibrosis according to newborn screening results

BACKGROUND

Cystic fibrosis (CF) is a lethal recessive genetic disease caused by loss of function associated with mutations in the CF trans-membrane conductance regulator. It is highly prevalent (approximately 1 in 3,500) in Caucasians. The aim of this study was to compare demographic and clinical features, diagnostic tests, treatments, and complications of patients with CF whose newborn screening (NBS) with twice-repeated immune reactive trypsinogen testing was positive, normal, and not performed.

METHODS

In this study, 359 of all 1,488 CF patients recorded in the CF Registry of Turkey in 2018, who had been born through the process of NBS, were evaluated. Demographic and clinical features were compared in patients diagnosed with positive NBS (Group 1), normal (Group 2), or without NBS (Group 3).

RESULTS

In Group 1, there were 299 patients, in Group 2, there were 40 patients, and in Group 3, there were 20 patients. Among all patients, the median age at diagnosis was 0.17 years. The median age at diagnosis was higher in Groups 2 and 3 than in Group 1 (P = 0.001). Fecal elastase results were higher in Group 2 (P = 0.033). The weight z-score was lower and chronic Staphylococcus aureus infection was more common in Group 3 (P = 0.017, P = 0.004, respectively).

CONCLUSIONS

Frequency of growth retardation and chronic S. aureus infection can be reduced with an early diagnosis using NBS. In the presence of clinical suspicion in patients with normal NBS, further analyses such as genetic testing should be performed, especially to prevent missing patients with severe mutations.

The ISPAT project: Implementation of a standardized training program for caregivers of children with tracheostomy

BACKGROUND

Tracheostomy-related morbidity and mortality mainly occur due to decannulation, misplacement, or obstruction of the tube. A standardized training can improve the skills and confidence of the caregivers in tracheostomy care (TC).

OBJECTIVE

Our primary aim was to evaluate the efficiency of standardized training program on the knowledge and skills (changing-suctioning the tracheostomy tube) of the participants regarding TC.

MATERIALS AND METHODS

Sixty-five caregivers of children with tracheostomy were included. First, participants were evaluated with written test about TC and participated in the practical tests. Then, they were asked to participate in a standardized training session, including theoretical and practical parts. Baseline and postintervention assessments were compared through written and practical tests conducted on the same day.

RESULTS

A significant improvement was observed in the written test score after the training. The median number of correct answers of the written test including 23 questions increased 26%, from 12 to 18 (p < .001). The median number of correct steps in tracheostomy tube change (from 9 to 16 correct steps out of 16 steps, 44% increase) and suctioning the tracheostomy tube (from 9 to 17 correct steps out of 18 steps, 44% increase) also improved significantly after the training (p < .001, for both).

CONCLUSION

Theoretical courses and practical hands-on-training (HOT) courses are highly effective in improving the practices in TC. A standardized training program including HOT should be implemented before discharge from the hospital. Still there is a need to assess the impact of the program on tracheostomy-related complications, morbidity, and mortality in the long term.

Evaluation of the health-related quality of life in Turkish cystic fibrosis patients

BACKGROUND

Prolongation of life expectancy in cystic fibrosis (CF) to the fourth decade makes health-related quality of life (HRQOL) an important issue in this population. This study aims to evaluate the effects of clinical and socio-demographic characteristics of patients on different aspects of HRQOL in a pediatric CF population. We also intend to assess some measures of reliability and validity of the Turkish CF Questionnaire-Revised (CFQ-R) forms.

METHODS

Fifty-four CF patients and 46 parents / caregivers filled the appropriate CFQ-R forms. Disease severity was evaluated via modified Shwachman-Kulczycki (SK) scores, and additional clinical information was obtained from patient records.

RESULTS

Forty-three percent (n = 23) of patients were female, the mean age of patients being 13.3 ± 3.96 years. Self- and proxy-reported points showed a strong correlation (Spearman's rho > 0.6) on more observable domains of HRQOL (e.g. physical functioning). No significant difference was found between sexes on any HRQOL domain. When compared between age groups, treatment burden appeared to worsen with age, while social functioning improved. All three forms of the CFQ-R Turkish version showed acceptable internal consistency reliability and convergence with disease severity measures.

CONCLUSIONS

The CFQ-R showed a fair correlation with the Shwachman-Kulczycki score and the FEV1% value, which makes its longitudinal use possible in clinical practice. It is important to use self-reported evaluations as well as parent / caregiver-reported HRQOL evaluations, especially in young children. More studies are needed to assess the psychometric properties of Turkish CFQ-R forms.

Effects of long-term azithromycin therapy on auditory functions in children with chronic respiratory diseases

BACKGROUND AND OBJECTIVES

In recent years, long-term azithromycin (AZT) use has been increased in pediatric patients with chronic respiratory tract problems. In this study, we aimed to assess auditory functions in children on long-term AZT therapy.

METHOD

The study included 43 patients who received long-term AZT treatment and 27 age-matched, healthy controls. In the study and control groups, ear-nose-throat examination, pure tone audiometry, speech recognition threshold (SRT), speech discrimination score (SDS), uncomfortable loudness level (UCL), acoustic reflex tests, and otoacoustic emission tests were performed. The test results were statistically compared between groups.

RESULTS

Mean age was 11.3 ± 0.56 years in the study group and 9.3 ± 3.07 years in the control group. The medain hearing examination was 8 months after end of AZT treatment (Ranged: 1-12 months). No significant difference was found in normal- and high-frequency audiogram tests at any frequency between study and control groups. Also, no significant difference was found in distortion product otoacoustic emissions (DPOAE) and transient evoked otoacoustic emissions (TEOAE) tests between groups. Also, there was no significant difference in acoustic reflex, SRT, SDS, and UCL test results between study and control groups.

CONCLUSION

This is the first study assessing auditory functions comprehensively in pediatric patients who received long-term AZT therapy. In this study, it was shown that long-term AZT use had no deleterious effect on auditory function tests.

Relationships Between Bronchoscopy, Microbiology, and Radiology in Noncystic Fibrosis Bronchiectasis

Background: Published data on the correlations of bronchoscopy findings with microbiological, radiological, and pulmonary function test results in children with noncystic fibrosis (CF) bronchiectasis (BE) are unavailable. The aims of this study were to evaluate relationships between Bronchoscopic appearance and secretion scoring, microbiological growth, radiological severity level, and pulmonary function tests in patients with non-CF BE. Methods: Children with non-CF BE were identified and collected over a 6-year period. Their medical charts and radiologic and bronchoscopic notes were retrospectively reviewed. Results: The study population consisted of 54 female and 49 male patients with a mean age of 11.7 ± 3.4 years. In the classification according to the bronchoscopic secretion score, Grade I was found in 2, Grade II in 4, Grade III in 9, Grade IV in 17, Grade V in 25, and Grade VI in 46 patients. When evaluated according to the Bhalla scoring system, 45 patients had mild BE, 37 had moderate BE, and 21 had severe BE. Microbial growth was detected in bronchoalveolar lavage fluid from 50 of the patients. Forced expiratory volume in 1 s (FEV₁) and functional vital capacity decreased with increasing bronchoscopic secretion grade (P = 0.048 and P = 0.04), respectively. The degree of radiological severity increased in parallel with the bronchoscopic secretion score (P = 0.007). However, no relationship was detected between microbiological growth rate and radiological findings (P = 0.403). Conclusions: This study showed that bronchoscopic evaluation and especially scoring of secretions correlate with severe clinical condition, decrease in pulmonary function test, worsening in radiology scores, and increase in microbiological bacterial load in patients. Flexible endoscopic bronchoscopy should be kept in mind in the initial evaluation of non-CF BE patients.

Effect of expiratory muscle training on peak cough flow in children and adolescents with cystic fibrosis: A randomized controlled trial

BACKGROUND

Cough is an important defense and airway clearance mechanism for removing thick and viscous secretions in cystic fibrosis (CF). The primary aim of this study was to investigate the effect of expiratory muscle training (EMT) on peak cough flow (PCF) and secondly on respiratory muscle functions, functional exercise capacity, and quality of life (QoL) in CF.

METHODS

Thirty patients were randomized as training and sham groups. Both groups were trained with the EMT protocol, which involved twice per day for at least 5 days per week for 6 weeks. The training intensity in the training group was 30% of the maximal expiratory pressure (MEP). In the sham group, it remained at the lowest pressure (5 cmH₂ O). The primary outcome was PCF. The secondary outcomes were MEP, maximal inspiratory pressure (MIP), spirometric measures, six-minute walking distance (6MWD), and QoL (Cystic Fibrosis Questionnaire-Revised).

RESULTS

Twenty-eight patients completed the study. Changes in PCF (p = .041) and MEP (p = .003) were higher in the training group than the sham group. Also, treatment burden (p = .008), digestive symptoms (p = .019), and vitality (p = .042) in QoL were more improved in the training group. MIP (p = .028) and 6MWD (p = .035) changed significantly only in the training group. Spirometric measurements did not change (p > .05).

CONCLUSIONS

The results of the study show that EMT could improve PCF, MEP, treatment burden, digestive symptoms, and vitality domains of QoL in patients with CF. Moreover, MIP and functional exercise capacity improved in the training group with EMT.

General health status of children with asthma during the COVID-19 pandemic

BACKGROUND

Since the COVID-19 pandemic became a serious health concern globally, patients with chronic diseases have required close attention with regard to general risks and individual treatment. We aimed to reveal the general health status of pediatric asthmatic patients during the pandemic, considering the role of household factors in parental attitudes.

METHODS

We asked 60 asthmatic patients and their parents to respond to a questionnaire, with the aim of revealing the current health status of the patients and the general approach of the family to asthma management during the pandemic.

RESULTS

A total of eight patients had had an asthma attack during the outbreak, but there was no confirmed correlation with COVID-19 infection. Most of the parents had never considered stopping their children's current medications. However, the majority of them reported concerns about the failure of the ambulatory care services and almost all saw their children as being at high risk for COVID-19 infection. There was no significant relationship between these concerns and their psychological status (P > 0.05).

CONCLUSIONS

The crucial point regarding asthma management is to control patients' medical and psychological status to minimize the effects of the pandemic. Healthcare professionals should also pay attention to members of the patients' households because their adaptation to the "new normal" of pandemic may directly affect the patients' state of health.

The effects of nutritional status and intervention on pulmonary functions in pediatric cystic fibrosis patients

BACKGROUND

Cystic fibrosis (CF) causes malabsorption of nutrients that exacerbate pulmonary problems. Nutritional interventions can improve pulmonary functions. We aimed to evaluate the effects of nutritional intervention in CF patients with malnutrition, and to determine if there is a correlation between nutritional status and pulmonary functions.

METHODS

The study included 143 CF patients (67 females) with a mean 2 year follow-up time. Patients' sociodemographic data, presenting symptoms and history were recorded. Height-for-age, weight-for-age, weight-for-length/height (WFL/H), and body mass index (BMI) were calculated in all patients. Patients were grouped as well nourished, mild malnutrition, moderate malnutrition, and severe malnutrition. These four groups were compared in terms of pulmonary function test results, lung infections, and the hospitalization rate.

RESULTS

Among the patients with a WFL/H or BMI z-scores that decreased, the frequency of lung infection was 74.1% and the hospitalization rate was 40.7%, versus 34% and 12.3%, respectively among the patients with a WFL/H or BMI z-scores that increased. The difference was significant (P = 0.02 and P = 0.01, respectively). The difference in bacterial lung infections differed significantly between the four nutritional status groups (P = 0.002). Patients in the well-nourished group had significantly higher pulmonary function test scores than the other groups. The forced expiratory volume in the first second differed significantly between the patients with and without an increase in the WFL/H or BMI z-scores (P = 0.001).

CONCLUSIONS

The appropriate nutritional intervention to pediatric CF patients with malnutrition, decrease the frequency of lung infections, and improve respiratory function.

Determination of tuberculin skin test for isoniazid prophylaxis in BCG vaccinated children who are using anti-TNF agents for rheumatologic diseases

OBJECTIVE

The use of tumor necrosis factor inhibitors (anti-TNF) has a risk of activating latent tuberculosis infection (LTBI). This study was performed to investigate LTBI according to tuberculin skin test (TST) size and to determine the frequency of tuberculosis (TB) in bacillus Calmette-Guerin (BCG)-vaccinated children receiving anti-TNF treatment for rheumatological disease.

MATERIALS AND METHODS

The study consisted of 559 children. Information on demographics, anti-TNF agents, TST size, and isoniazid (INH) prophylaxis was recorded. Patients (n = 254) with TST size ≥5 mm were divided into three groups according to TST size and INH prophylaxis: group 1, TST size 5 to 9 mm and no INH prophylaxis; group 2, TST size 5 to 9 mm with INH prophylaxis; and group 3, TST size ≥10 mm with INH prophylaxis.

RESULTS

The 559 patients comprised 314 (56.3%) females and 245 (43.6%) males; they had a mean age of 13.1 ± 4.1 years. The mean TST size in all patients was 4.2 ± 4.7 mm. Group 1 consisted of 76 (29.9%) patients, group 2 consisted of 88 (34.6%) patients, and group 3 consisted of 90 (35.4%) patients. The mean TST sizes for the three groups were 6.8 ± 3.1 mm, 7.2 ± 3.2 mm, and 13.9 ± 2.8 mm, respectively. New TB was diagnosed in only two (0.35%) patients. Both of them were in group 3.

CONCLUSIONS

A TST size of ≥10 mm in BCG-vaccinated children receiving anti-TNF treatment may distinguish children at high risk for reactivation of LTBI.

Clinical characteristics and genetic analysis of cystic fibrosis transmembrane conductance reseptor-related disease

BACKGROUND

Cystic fibrosis (CF) transmembrane conductance receptor (CFTR)-related disease is diagnosed in patients affected by CFTR dysfunction who do not fully meet the CF diagnostic criteria. Only 2% of all CF patients have CFTR-related disease. We define the demographic characteristics of such patients, described the performance of mutational analyses, and describe the clinical findings.

METHODS

Twenty-four patients were followed-up for CFTR-related disease. Patients with CF symptoms but who did not completely fulfil the CF diagnostic criteria were enrolled. Age, body mass index at the times of diagnosis and admission, symptoms, pulmonary function and fecal elastase test results, gene analyses, and clinical findings during follow-up were evaluated.

RESULTS

Ten patients (42%) were female and 14 (58%) male. Their mean age was 15.3 years (minimum-maximum 6-20 years). The mean age at diagnosis was 8.5 years (minimum-maximum 3-14 years) and the most common presenting complaint was a cough (n = 19). During follow up, chronic sinusitis developed in 15 patients, bronchiectasis in 13, nasal polyposis in six, failure to thrive in three, recurrent pancreatitis in two, asthma in one, and congenital bilateral absence of the vas deferens in one. Fecal elastase levels were low in only one of the three patients who failed to thrive. In terms of CFTR gene mutations, two were found in 10 patients, one in eight patients, and none in six.

CONCLUSIONS

Cystic fibrosis transmembrane conductance receptor-related disease presents with various clinical findings. Serious symptoms may develop later in life. Late diagnosis significantly compromises the quality and duration of life in such patients.