Cystic fibrosis related diabetes is not associated with maximal aerobic exercise capacity in cystic fibrosis: a cross-sectional analysis of an international multicenter trial

BACKGROUND

Previous studies have reported differences in aerobic exercise capacity, expressed as peak oxygen uptake (VO_2peak), between people with and without cystic fibrosis (CF) related diabetes (CFRD). However, none of the studies controlled for the potential influence of physical activity on VO_2peak. We investigated associations between CFRD and VO_2peak following rigorous control for confounders including objectively measured physical activity.

METHODS

Baseline data from the international multicenter trial ACTIVATE-CF with participants ≥12 years performing up to 4 h per week of vigorous physical activity were used for this project. Multivariable models were computed to study associations between CFRD and VO_2peak (mL.min^-1) adjusting for a set of pre-defined covariates: age, sex, weight, forced expiratory volume in 1 s (FEV₁), breathing reserve index, Pseudomonas aeruginosa infection, and physical activity (aerobic step counts from pedometry). Variables were selected based on their potential confounding effect on the association between VO_2peak and CFRD.

RESULTS

Among 117 randomized individuals, 103 (52% female) had a maximal exercise test and were included in the analysis. Participants with (n = 19) and without (n = 84) CFRD did not differ in FEV₁, physical activity, nutritional status, and other clinical characteristics. There were also no differences in VO_2peak (mL.min^-1 or mL.kg^-1.min^-1 or% predicted). In the final multivariable model, all pre-defined covariates were significant predictors of VO_2peak (mL.min^-1), however CFRD [coefficient 82.1, 95% CI -69.5 to 233.8, p = 0.28] was not.

CONCLUSIONS

This study suggests no meaningful differences in VO_2peak between people with and without CFRD given comparable levels of physical activity.

Effects of a Partially Supervised Conditioning Program in Cystic Fibrosis: An International Multicenter Randomized Controlled Trial (ACTIVATE-CF)

Rationale

The long-term effects of vigorous physical activity (PA) on lung function in cystic fibrosis are unclear.

Objectives

To evaluate effects of a 12-month partially supervised PA intervention using motivational feedback.

Methods

In a parallel-arm multicenter randomized controlled trial (ACTIVATE-CF), relatively inactive patients aged at least 12 years were randomly assigned (1:1 ratio) to an intervention group or control group. The intervention group consented to add 3 hours of vigorous PA per week, whereas the control group was asked not to change their PA behavior. Primary endpoint was change in percent predicted FEV₁ (ΔFEV₁) at 6 months. Secondary endpoints included PA, exercise capacity, exercise motives, time to first exacerbation and exacerbation rates, quality of life, anxiety, depression, stress, and blood glucose control. Data were analyzed using mixed linear models.

Measurements and Main Results

A total of 117 patients (40% of target sample size) were randomized to an intervention (n = 60) or control group (n = 57). After 6 months, ΔFEV₁ was significantly higher in the control group compared with the intervention group (2.70% predicted [95% confidence interval, 0.13–5.26]; P = 0.04). The intervention group reported increased vigorous PA compared with the control group at each study visit, had higher exercise capacity at 6 and 12 months, and higher PA at 12 months. No effects were seen in other secondary outcomes.

Conclusions

ACTIVATE-CF increased vigorous PA and exercise capacity, with effects carried over for the subsequent 6 months, but resulted in better FEV₁ in the control group.

Prevalence and clinical associations of Staphylococcus aureus small-colony variant respiratory infection in children with cystic fibrosis (SCVSA): a multicentre, observational study

BACKGROUND

Staphylococcus aureus is the bacterium cultured most often from respiratory secretions of people with cystic fibrosis. Both meticillin-susceptible S aureus and meticillin-resistant S aureus (MRSA) can adapt to form slow-growing, antibiotic-resistant isolates known as small-colony variants that are not routinely identified by clinical laboratories. We aimed to determine the prevalence and clinical significance of S aureus small-colony variants and their subtypes among children with cystic fibrosis.

METHODS

The Small Colony Variant Staphylococcus aureus (SCVSA) study was a 2-year longitudinal study of children aged 6-16 years at five US cystic fibrosis centres, using culture methods sensitive for small-colony variants. Children were eligible if they had a documented diagnosis of cystic fibrosis and a minimum of two cystic fibrosis clinic visits and two respiratory cultures in the previous 12 months at enrolment. Participants attended clinic visits quarterly, at which respiratory tract samples were taken and measures of lung function (percentage of predicted forced expiratory volume in 1 s [FEV₁] and frequency of respiratory exacerbations) were recorded. We determined the prevalence of small-colony variants and their subtypes, and assessed their independent associations with lung function and respiratory exacerbations using linear mixed-effects and generalised estimating equation logistic regression models. Analyses included both univariate models (unadjusted) and multivariate models that adjusted for potential confounders, including age, sex, race, baseline microbiology, treatment with CFTR modulator, and CTFR genotype.

FINDINGS

Between July 1, 2014, and May 26, 2015, we enrolled 230 children. Participants were followed-up for 2 years, with a mean of 6·4 visits (SD 1·14) per participant (range 2-9 visits) and a mean interval between visits of 3·94 months (SD 1·77). Across the 2-year period, S aureus small-colony variants were detected in 64 (28%) participants. Most (103 [56%] of 185) of the small-colony variants detected in these participants were thymidine dependent. Children with small-colony variants had significantly lower mean percentage of predicted FEV₁ at baseline than did children without small-colony variants (85·5 [SD 19] vs 92·4 [SD 18·6]; p=0·0145). Small-colony variants were associated with significantly lower percentage of predicted FEV₁ throughout the study in regression models, both in univariate analyses (regression coefficient -7·07, 95% CI -12·20 to -1·95; p=0·0068) and in multivariate analyses adjusting for potential confounders (-5·50, -10·51 to -0·48; p=0·0316). Small colony variants of the thymidine-dependent subtype had the strongest association with lung function in multivariate regression models (regression coefficient -10·49, -17·25 to -3·73; p=0·0024). Compared with children without small-colony variants, those with small-colony variants had significantly increased odds of respiratory exacerbations in univariate analyses (odds ratio 1·73, 95% CI 1·19 to 2·52; p=0·0045). Children with thymidine-dependent small-colony variants had significantly increased odds of respiratory exacerbations (2·81, 1·69-4·67; p=0·0001), even after adjusting for age, sex, race, genotype, CFTR modulator, P aeruginosa culture status, and baseline percentage of predicted FEV₁ (2·17, 1·33-3·57; p=0·0021), whereas those with non-thymidine-dependent small-colony variants did not. In multivariate models including small-colony variants and MRSA status, P aeruginosa was not independently associated with lung function (regression coefficient -4·77, 95% CI -10·36 to 0·83; p=0·10) and was associated with reduced odds of exacerbations (0·54, 0·36 to 0·81; p=0·0028). Only the small-colony variant form of MRSA was associated with reduced lung function (-8·44, -16·15 to -0·72; p=0·0318) and increased odds of exacerbations (2·15, 1·24 to 3·71; p=0·0061).

INTERPRETATION

Infection with small-colony variants, and particularly thymidine-dependent small-colony variants, was common in a multicentre paediatric population with cystic fibrosis and associated with reduced lung function and increased risk of respiratory exacerbations. The adoption of small-colony variant identification and subtyping methods by clinical laboratories, and the inclusion of small-colony variant prevalence data in cystic fibrosis registries, should be considered for ongoing surveillance and study.

FUNDING

The Cystic Fibrosis Foundation and the National Institutes of Health.

Effects of an Antioxidant-enriched Multivitamin in Cystic Fibrosis. A Randomized, Controlled, Multicenter Clinical Trial

RATIONALE

Cystic fibrosis (CF) is characterized by dietary antioxidant deficiencies, which may contribute to an oxidant-antioxidant imbalance and oxidative stress.

OBJECTIVES

Evaluate the effects of an oral antioxidant-enriched multivitamin supplement on antioxidant concentrations, markers of inflammation and oxidative stress, and clinical outcomes.

METHODS

In this investigator-initiated, multicenter, randomized, double-blind, controlled trial, 73 pancreatic-insufficient subjects with CF 10 years of age and older with an FEV1 between 40% and 100% predicted were randomized to 16 weeks of an antioxidant-enriched multivitamin or control multivitamin without antioxidant enrichment. Endpoints included systemic antioxidant concentrations, markers of inflammation and oxidative stress, clinical outcomes (pulmonary exacerbations, anthropometric measures, pulmonary function), safety, and tolerability.

MEASUREMENTS AND MAIN RESULTS

Change in sputum myeloperoxidase concentration over 16 weeks, the primary efficacy endpoint, was not significantly different between the treated and control groups. Systemic antioxidant (β-carotene, coenzyme Q10, γ-tocopherol, and lutein) concentrations significantly increased in the antioxidant-treated group (P < 0.001 for each), whereas circulating calprotectin and myeloperoxidase decreased in the treated group compared with the control group at Week 4. The treated group had a lower risk of first pulmonary exacerbation requiring antibiotics than the control group (adjusted hazard ratio, 0.50; P = 0.04). Lung function and growth endpoints did not differ between groups. Adverse events and tolerability were similar between groups.

CONCLUSIONS

Antioxidant supplementation was safe and well tolerated, resulting in increased systemic antioxidant concentrations and modest reductions in systemic inflammation after 4 weeks. Antioxidant treatment was also associated with a lower risk of first pulmonary exacerbation. Clinical trial registered with www.clinicaltrials.gov (NCT01859390).

Effects of a partially supervised conditioning programme in cystic fibrosis: an international multi-centre randomised controlled trial (ACTIVATE-CF): study protocol

BACKGROUND

Physical activity (PA) and exercise have become an accepted and valued component of cystic fibrosis (CF) care. Regular PA and exercise can positively impact pulmonary function, improve physical fitness, and enhance health-related quality of life (HRQoL). However, motivating people to be more active is challenging. Supervised exercise programs are expensive and labour intensive, and adherence falls off significantly once supervision ends. Unsupervised or partially supervised programs are less costly and more flexible, but compliance can be more problematic. The primary objective of this study is to evaluate the effects of a partially supervised exercise intervention along with regular motivation on forced expiratory volume in 1 s (FEV₁) at 6 months in a large international group of CF patients. Secondary endpoints include patient reported HRQoL, as well as levels of anxiety and depression, and control of blood sugar.

METHODS/DESIGN

It is planned that a total of 292 patients with CF 12 years and older with a FEV₁ ≥ 35% predicted shall be randomised. Following baseline assessments (2 visits) patients are randomised into an intervention and a control group. Thereafter, they will be seen every 3 months for assessments in their centre for one year (4 follow-up visits). Along with individual counselling to increase vigorous PA by at least 3 h per week on each clinic visit, the intervention group documents daily PA and inactivity time and receives a step counter to record their progress within a web-based diary. They also receive monthly phone calls from the study staff during the first 6 months of the study. After 6 months, they continue with the step counter and web-based programme for a further 6 months. The control group receives standard care and keeps their PA level constant during the study period. Thereafter, they receive the intervention as well.

DISCUSSION

This is the first large, international multi-centre study to investigate the effects of a PA intervention in CF with motivational feedback on several health outcomes using modern technology. Should this relatively simple programme prove successful, it will be made available on a wider scale internationally.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01744561 ; Registration date: December 6, 2012.

Provider and Patient Attitudes Regarding Sexual Health in Young Women With Cystic Fibrosis

OBJECTIVE

To explore the attitudes, preferences, and experiences of patients with cystic fibrosis (CF) and CF providers toward sexual and reproductive health (SRH) care for young women with CF.

METHODS

Young women with CF aged 18 to 30 years from a US CF care center and pediatric and adult CF program directors from a national sample participated in qualitative interviews investigating their experiences regarding SRH care and their attitudes and preferences toward SRH care provision in the CF setting. Interviews were audio-recorded, transcribed, and coded by using a thematic analysis approach.

RESULTS

Twenty-two patient participants and 16 CF program directors were interviewed. Themes shared by both groups included the importance of SRH discussion in the CF care setting, patient and provider discomfort as a barrier to SRH care, and the need for SRH educational resources and provider training to improve SRH care. Providers highlighted the lack of standardization around SRH care in the current CF care model. Patients desired SRH educational resources coupled with early SRH discussions initiated by their CF provider.

CONCLUSIONS

Both CF providers and patients agree that the CF provider has a fundamental role in providing CF-specific SRH care. Educational resources coupled with individualized SRH discussions may facilitate improved SRH care for young women with CF. Investigation into the implementation of SRH education and services into pediatric-onset chronic disease care models is needed.

Cystic fibrosis program directors' attitudes toward sexual and reproductive health in young women with CF

INTRODUCTION

Advancements in therapy have led to dramatic increases in the life expectancy of patients with cystic fibrosis (CF). As survival improves, young women with CF will have expectations for their sexual and reproductive health (SRH) futures similar to their counterparts without CF. As they face unique CF-specific SRH concerns, they may rely on CF care providers for disease-specific SRH care provision. The purpose of this study was to investigate the attitudes of CF providers toward female SRH and perceived barriers in the current CF care model.

MATERIALS AND METHODS

U.S. CF program directors (n = 16) participated in qualitative interviews investigating attitudes and barriers to female CF SRH care. Interviews were audio-recorded, transcribed, and coded using a thematic analysis approach.

RESULTS

Participants (nine pediatric, five adult, and two combined) all agreed CF providers have a fundamental role in CF female SRH care. Most respondents named lack of time and patient and provider discomfort as significant barriers to effective SRH communication. Other reported barriers included: lack of training in SRH, family members in the room, low priority of SRH in setting of other CF issues, and lack of adequate rapport with patients.

DISCUSSION

This is the first study to assess the attitudes and experiences of CF care providers toward SRH discussion and care among female CF patients. Despite their perceived fundamental role in CF female SRH care, CF providers face significant barriers. Investment in provider training is needed to better address the complex SRH needs of young female patients.

How does heart rate recovery after sub-maximal exercise correlate with maximal exercise testing in children with CF?

BACKGROUND

Disease progression in cystic fibrosis (CF) is marked by worsening exercise tolerance. Further, maximal exercise capacity (VO2 peak) correlates with survival in CF, but maximal tests are uncomfortable and resource-intensive. A three-minute step test (STEP) has been validated in CF. Heart rate (HR) recovery after exercise correlates with all-cause mortality in adult non-CF populations. We compared HR recovery after the three-minute step test with VO2 peak in children with CF.

METHODS

Twenty-four children with CF performed STEP and a maximal exercise test. Correlation between the tests was assessed.

RESULTS

Maximum HR on STEP was lower than on the maximal test (140 vs. 190, p<0.01). Peak HR during STEP correlated inversely with VO2 peak. In subjects with mild lung disease, faster HR recovery after STEP correlated with higher VO2 peak.

CONCLUSIONS

The three-minute step test is a feasible submaximal test in this patient population. HR during and after a three-minute step test may reflect VO2 peak in children with CF.

Exercise intensity self-regulation using the OMNI scale in children with cystic fibrosis

Prescribing exercise at intensities that improve fitness is difficult in children with cystic fibrosis (CF) due to ventilatory limitations and fluctuating health status. Our aim was to determine if children with CF could regulate the intensity of cycle ergometer and treadmill exercise using target ratings of perceived exertion (RPE) derived from the Children's OMNI Scale. We examined prescription congruence (similar oxygen consumption [VO₂] and heart rate [HR] for target RPE) and intensity discrimination (different VO₂ and HR for different RPEs), from cycle to cycle and cycle to treadmill. Subjects were 24 children (12 male, 12 female), aged 10-17 years with varying disease severity. Each child participated in one orientation, one estimation trial (graded maximal exercise test), and two production trials (cycle and treadmill, alternating between RPE 4 and 7). At RPE 4, congruence was evident for both VO₂ and HR on the treadmill. On the cycle at RPE 4, VO₂ was significantly higher only in the first production trial, although HRs tended to be higher in the production trials than the estimation trial. Prescription congruence was also supported at RPE 7, with no significant differences in VO₂ or HR between estimation and production trials on cycle or treadmill. Results fully supported intensity discrimination, with significant differences between VO₂ and HR at RPE 4 and 7 (P < 0.0001). Children with CF appear capable of using the OMNI Scale to regulate cycle and treadmill exercise intensity. Training using this methodology has the potential to promote fitness in children with CF of varying severity.

Randomized trial of biofilm testing to select antibiotics for cystic fibrosis airway infection

RATIONALE

In cystic fibrosis (CF), conventional antibiotic susceptibility results correlate poorly with clinical outcomes. We hypothesized that biofilm testing would more accurately reflect the susceptibilities of bacteria infecting CF airways.

METHODS

A multicenter randomized pilot trial was conducted to assess the efficacy and safety of using biofilm susceptibility testing of Pseudomonas aeruginosa sputum isolates to guide antibiotic regimens for chronic airway infections in clinically stable adolescent and adult CF patients. Thirty-nine participants were randomized to biofilm or conventional treatment groups; 14-day courses of two antibiotics were selected according to an activity-based algorithm using the corresponding susceptibility results.

RESULTS

Of the agents tested, meropenem was most active against biofilm-grown bacteria, and was included in regimens for about half of each study group. For 19 of 39 randomized participants, randomization to the other study group would not have changed the antibiotic classes of the assigned regimen. Study groups were comparable at baseline, and had similar mean decreases in bacterial density, measured in log(10) colony forming units per gram of sputum (biofilm, -2.94 [SD 2.83] vs. conventional, -3.27 [SD 3.09]), and mean increases in forced expiratory volume in 1 sec, measured in liters (0.18 [SD 0.20] vs. 0.12 [SD 0.22]).

CONCLUSIONS

In this pilot study, antibiotic regimens based on biofilm testing did not differ significantly from regimens based on conventional testing in terms of microbiological and clinical responses. The predictive value of biofilm testing may nonetheless warrant evaluation in an adequately powered clinical trial in younger CF patients or those experiencing acute pulmonary exacerbation.

Effects of an exercise program in children with cystic fibrosis: are there differences between females and males?

OBJECTIVE

To investigate the adaptive responses of an in-patient exercise program in children with cystic fibrosis (CF) and evaluate the effects of sex.

STUDY DESIGN

In total, 158 female and 186 male subjects with CF (age, 12 to 43 years) were studied during a 6-week rehabilitation course. A maximal incremental cycling test was used to determine exercise capacity and responses after 6 weeks of exercise training. Measures included lung function, peak oxygen uptake, peak workload, and peak heart rate.

RESULTS

Lung function values were lower in males (P < .05). Females had a lower aerobic capacity (P < .05) at the beginning and at the end of the exercise training program. Similar training effects (P > .05) were seen between sexes in peak oxygen uptake (mL/min, mL/kg/min) and peak heart rate (beats/min) but not in peak workload (Watts, W/kg).

CONCLUSIONS

The exercise program improved the fitness level similarly in females and males with CF. Basic physiological sex differences were still seen at the beginning and end of the training, despite the better lung function in females. Moreover, the finding suggested that fitness level and not lung function determined the response to training in CF, with those who were less fit at baseline having the largest response to training.

Motor performance is better than normal in preschool children with cystic fibrosis

The aim of the present study was to assess the motor performance in preschool children with a reliable and valid test battery developed to identify motor dysfunction and normal motor development in children aged from 4 to 6 years. Several aspects of motor performance were examined in 29 preschool children with cystic fibrosis (CF) age range 4-6 years (mean 5.2 +/- 0.8 years), FEV(1) 97.2 +/- 15.3pred and compared to with 22 healthy children of the same age 5.5 +/- 0.8 years. All children performed the "Motoriktest fuer 4-6jaehrige Kinder" (MOT) assessing seven different aspects of motor performance. Compared to healthy children, test score "Motor Quotient" (MQ) as the mean of all test items was significantly higher (P < 0.05) in children with CF (108.1 +/- 16 vs. 93.5 +/- 17.9). In both groups, the MQ can be classified as normal. Children with CF scored higher in MOT subtests "Agility and Coordination" (P < 0.05) and "Balance" (P < 0.01) than healthy children but not in the other subtests. We speculate that chest physiotherapy in preschool children with CF may have an effect on motor performance in general and in some aspects of motor performance.

Health-related fitness and trainability in children with cystic fibrosis

The objective of this study was to examine the effects of a supervised exercise training program performed during an in patient rehabilitation course on various attributes of health-related fitness, e.g., flexibility, balance and coordination. 286 patients with CF, age range 6-18 years (11.8 +/- 3.4 years), mean forced expiratory volume in 1 sec (FEV1 82.7 +/- 22.3% predicted) were included. Patients performed the modified Munich fitness test (mMFT) to assess flexibility, balance, strength and coordination. To assess aerobic capacity a 6-min walk-test (6MWT) was performed. In addition, some of the patients performed an incremental exercise test on a bicycle ergometer using the Godfrey protocol before and after the exercise training program. The supervised training program consisted of 4-6 weeks of different sports activities 5 times per week. After training, pulmonary function showed a significant (P < 0.05) increase. All test items of the mMFT improved significantly (P < 0.05). Compared to healthy children test scores achieved from children with CF in the mMFT were lower but within a normal range. Our children with CF had a lower walk distance in 6MWT (P < 0.05) compared to healthy. Our findings clearly demonstrated benefits of a systematic exercise training program on components of physical fitness in patients with CF, with improvements of test-tasks to predicted normal in some cases. The results from our study suggested that an exercise training program in CF should be focused on several aspects of physical fitness including all components of physical fitness, e.g. aerobic endurance, flexibility, balance and motor skills.

Update on the role of exercise in cystic fibrosis

PURPOSE OF REVIEW

The role of exercise in patients with cystic fibrosis has been recognized for as long as cystic fibrosis has been identified as a clinical syndrome, as exercise intolerance has always been a hallmark of disease progression.

RECENT FINDINGS

Work published in the past year has shed new light on several aspects of this field, including physiologic responses to exercise, responses to exercise programs, and the epidemiologic and prognostic implications of activity and exercise testing.

SUMMARY

Barker's work is perhaps the most compelling, as it highlights the overwhelming interest and belief in the utility of exercise testing and prescription among cystic fibrosis physicians and the contrasting paucity of programs that test their patients and prescribe exercise for them. More studies are needed to identify the form of exercise programs and tests that are most likely to be effective and to be used by cystic fibrosis centers and patients.

Strength vs Aerobic Training in Children With Cystic Fibrosis

STUDY OBJECTIVE

Exercise has the potential to improve the ability of a patient with cystic fibrosis (CF) to cope with the physical demands of everyday life, and may improve prognosis. The purpose of this study was to compare the effects of a home-based, semi-supervised, upper-body strength-training regimen with a similarly structured aerobic training regimen.

DESIGN

Data were collected during a 1-year randomized clinical trial.

SETTING

Counselors conducted in-home visits with the participants once per week for the first 8 weeks followed by monthly visits for the remainder of the study.

PATIENTS

Sixty-seven patients with CF, aged 8 to 18 years, participated in the trial.

INTERVENTION

Participants in both exercise conditions were encouraged to exercise at least three times per week for 1 year. Each child in the aerobic group was given a stair-stepping machine, and each child in the upper-body strength training group was given an upper-body-only weight-resistance machine.

MEASURES AND RESULTS

Aerobic fitness, pulmonary function, quality of life, and strength were measured at baseline, at 6 months, and at 12 months. Strength training increased the maximum weight lifted for biceps curls significantly more than aerobic training (p < 0.02). However, this differential did not remain significant after control for increase in height. Both training procedures were associated with increased strength (p < 0.002) and physical work capacity (PWC) [p < 0.033].

CONCLUSIONS

We concluded that strength and aerobic training may increase upper-body strength, and that both types of training may increase PWC for children with CF. Future trials should be conducted with no-training control subjects and larger samples to increase statistical power.

Liver transplantation in children with cystic fibrosis: a long-term longitudinal review of a single center's experience

BACKGROUND

Improved long-term survival in cystic fibrosis (CF) has led to an increased incidence of extrapulmonary complications of this disease. Of these, end-stage liver disease is a significant cause of morbidity and mortality with liver transplantation being the only effective therapy.

METHODS

Records of all CF pediatric liver transplant recipients were reviewed.

RESULTS

Twelve children with CF were the recipients of 16 allografts. The 1- and 5-year survival was 91.6% and 75%, respectively. There were 5 deaths at a mean interval of 6.8 +/- 6.3 years. All of these deaths were related to pulmonary disease. Pulmonary function improved or remained stable in 8 of 9 patients tested. Despite an 83% incidence of positive sputum cultures, there was only one early mortality related to pulmonary sepsis in the setting of primary liver allograft nonfunction.

CONCLUSIONS

Liver transplantation is acceptable treatment for children with CF and end-stage liver disease. Long-term survival is comparable to liver transplantation performed for other indications. Although posttransplant morbidity and mortality is related to lung disease, the authors speculate that as therapeutic improvements prolong the survival in CF, it is expected that longer survival after liver transplantation in this patient population may also be anticipated.

Measuring ease of breathing in young patients with cystic fibrosis

Our objective was to compare two new objective measures of ease of breathing with the visual analog scale (VAS). Twenty-eight patients with CF, 7-34 years old (FEV(1) 25-114% of predicted), enrolled. Ease of breathing was evaluated by a standard 10-cm VAS, maximum phonation (time, in seconds, to sustain the syllable "Ahh") using a single breath, and counting in a single breath at one number per second (Count) at rest, following 3 min of stepping exercise at 15 steps per minute (STEP15), and 3 min at 30 steps per minute (STEP30). Heart rate (HR) and oxyhemoglobin saturation (SaO(2)) were measured.HR and VAS increased significantly, and SaO(2), phonation, and Count decreased significantly from rest to STEP15 and STEP30. Phonation time correlated significantly (and inversely) with HR after exercise. Phonation time was positively correlated with SaO(2) at rest and after STEP30. Counts at rest and after STEP30 were significantly related to SaO(2). VAS showed no relationship to heart rate at rest or after exercise, but was related to SaO(2) at the end of STEP30. Test-retest reliability for three trials of phonation was 0.92, and for the five trials of counting was 0.93. Correlation coefficients for maximum phonation at rest, STEP15, and STEP30 on 2 separate days were 0.61, 0.94, and 0.91, respectively. Correlation coefficients for Count at rest, STEP15, and STEP30 on 2 separate days were 0.96, 0.94, and 0.94, respectively. Correlation coefficients for VAS at rest, STEP15, and STEP30 on 2 separate days were 0.25, 0.89, and 0.97, respectively. Thus both the maximum phonation and Count have good test-retest reliability within one session, and across 2 separate days, for both rest and exercise conditions. In conclusion, maximum phonation and Count are valid and reliable measures of ease of breathing; they reflect increasing work loads and show stronger correlations with heart rate and SaO(2) than does VAS. These measures could be an important tool for clinical research and patient care.

Pulmonary problems and management concerns in youth sports

In the overwhelming majority of exercising youngsters, exercise tolerance is limited by cardiovascular and muscular factors, not the lungs. Even at exhaustion, pulmonary reserve is considerable. Yet some young athletes do experience respiratory problems with exercise. These problems can be assigned to several categories, including those related to underlying acute and chronic respiratory conditions (principally respiratory tract infections, asthma, cystic fibrosis, chest wall deformities, and neuromuscular disorders), and apparent but nonpathological problems (the heavy breathing of anaerobic exercise, relative deconditioning, and anxiety). There are also situations that seem to be problematic but need not be (having the diagnosis of asthma or cystic fibrosis). Pharmacologic management of respiratory problems and perceived problems can be difficult and is discussed with the particular disorder.

Cystic fibrosis in three children with bronchopulmonary dysplasia

Cystic fibrosis (CF) and bronchopulmonary dysplasia (BPD) are two common causes of chronic lung disease in children. Patients with BPD or CF often have recurrent respiratory symptoms, failure to thrive, and/or metabolic alkalosis during infancy and childhood. Thus, recognizing the diagnosis of CF in an infant with BPD can be difficult. We present three infants with both BPD and CF. The infants shared a history of respiratory distress and prolonged oxygen requirements. All three also had difficulty gaining weight, even after pancreatic enzyme supplementation was instituted. Metabolic alkalosis was observed in two infants. Previous studies in children with CF suggest that early diagnosis may impact both lung health and nutritional status. A high index of suspicion is necessary for clinicians to identify these children early and intervene with appropriate therapy.

Habitual physical activity in children and adolescents with cystic fibrosis

PURPOSE

This study was conducted to: 1) measure total physical activity levels, including the intensities of the various types of activities, in children and adolescents with CF compared with non-CF healthy control subjects; and 2) determine whether vigorous activity level was related to aerobic fitness and disease status in patients with CF.

METHODS

Thirty patients with CF (18 male, 12 female) and 30 control subjects (17 male, 13 female), 7-17 yr old, participated in this study. Habitual physical activity was measured using Kriska's Modifiable Activity Questionnaire (MAQ) and the past year's average of total hours, MET-hours, and vigorous (VIG) hours (>6 METs) of activity per week were determined. Aerobic fitness was determined from peak oxygen uptake (VO2peak) obtained via maximal exercise testing on a cycle ergometer. Standard spirometry was used to measure pulmonary function. Body mass index (BMI) was determined from height and weight measurements.

RESULTS

The CF and control groups were similar in age and gender distribution, but the patients were smaller (BMI, 98 vs 112% of predicted) and less aerobically fit (36.5 vs 41.4 mL x kg(-1) x min(-1)). Total and MET-hours of physical activity did not differ between groups; however, the CF group participated in significantly fewer hours of vigorous activities than the control group (2 vs 3.7 h x wk(-1)). In patients with worse lung disease, VIG-h x wk(-1) were significantly related to VO2peak (r = 0.83).

CONCLUSION

These results suggest that children with CF engage in less vigorous physical activities than their healthy non-CF peers, despite having good lung function. In view of the progressive nature of the disease, and the association between aerobic fitness and vigorous activity, patients should be encouraged to engage in more vigorous activities that promote aerobic fitness and may ultimately have an impact on survival.

A comparison of the efficacy and tolerance of pancrelipase and placebo in the treatment of steatorrhea in cystic fibrosis patients with clinical exocrine pancreatic insufficiency

OBJECTIVE

The safety and efficacy of Minimicrospheres, which are enteric-coated, delayed-release pancrelipase capsules, on fat absorption in pediatric/adolescent and adult cystic fibrosis (CF) patients was assessed. Exocrine pancreatic insufficiency, common in CF patients, causes steatorrhea due to insufficient release of pancreatic enzymes.

METHODS

In the open-label phase, 97 CF patients with pancreatic insufficiency and steatorrhea were stabilized on a high-fat diet and administered pancrelipase. Seventy-four patients with >80% coefficient of fat absorption received placebo or pancrelipase in the double-blind phase. Fat intake and excretion, stool frequency and consistency, and clinical global improvement were recorded.

RESULTS

Average daily fat intake was comparable between treatment groups within each age group (adults vs pediatric/adolescent), but placebo patients had a significant (p < 0.001) mean decrease in coefficient of fat absorption (adult, 36.9 percentage points; pediatric/adolescent, 34.9 percentage points) from open-label to double-blind treatment compared to pancrelipase patients (adult, 2 percentage points; pediatric/adolescent, 3.25 percentage points); this difference was caused by a greater (p < or = 0.001) increase in mean fecal fat excretion (grams per day) in the placebo groups compared to pancrelipase groups (adult: 61.9 vs 2.3; pediatric/adolescent: 45.4 vs 4.1). Change in mean stool frequency from open-label to double-blind phases was significantly different (p < or = 0.002) between treatment groups, with increases in placebo groups and no difference (adult) or decrease (pediatric/adolescent) in pancrelipase groups. Pancrelipase patients' stool consistency remained about the same from open-label to double-blind. Placebo patients' stool consistency decreased (became softer) from open-label pancrelipase to double-blind placebo. Clinical global improvement data showed that > or =83% of pancrelipase patients improved or remained unchanged.

CONCLUSIONS

Enteric-coated, delayed-release (Minimicrospheres) pancrelipase capsules are an effective treatment for steatorrhea associated with pancreatic insufficiency in patients with cystic fibrosis.

An intrasylvian "fibroma" in a child with cystic fibrosis: case report

OBJECTIVE AND IMPORTANCE

Intracranial fibrous tumors are uncommon during childhood. An unusual case of benign intrasylvian "fibroma" that has remained clinically and radiographically stable more than 3 years after a subtotal resection is described.

CLINICAL PRESENTATION

A 9-year-old girl with cystic fibrosis presented with new-onset focal seizures referable to a large calcified left sylvian fissure mass.

INTERVENTION

An open biopsy with subtotal resection of the lesion revealed a benign process characterized by exuberant fibrocollagenous tissue intermeshed with chronic inflammatory cells and foreign body giant cells, encompassing islands of gliotic brain tissue. Immunohistochemical analysis showed staining for epithelial membrane antigen and reticulin within some of the spindle cells, although the majority were nonreactive. The majority of tumor cells exhibited staining for laminin; CD34 staining was absent. Ultrastructural studies were also suggestive of a fibroblastic rather than a meningothelial origin of the lesion, with elongated cells separated by abundant extracellular collagen. Although dense adherence of the mass to the pial surface and the middle cerebral artery vessels precluded a complete resection, the patient remains seizure-free without anticonvulsant therapy more than 3 years postoperatively with no evidence of growth of the lesion.

CONCLUSION

The lesion in this patient bears morphological similarity to a rare group of tumors referred to as "intracerebral fibromas," although a variety of other rare mesenchymal neoplasms were also considered within the differential diagnosis. However, the absence of any definite neoplastic features, the finding of chronic inflammatory changes, and the lack of growth of the residual tumor during an extended follow-up interval indicate that the mass may represent either an extremely indolent neoplasm or a nonneoplastic process. The differential diagnosis of intracranial fibrous tumors is contrasted with that of the reported case.

Comparison of Flutter device and chest physical therapy in the treatment of cystic fibrosis pulmonary exacerbation

Chest physiotherapy (CPT) is recommended for the clearance of bronchial secretions in the management of patients with cystic fibrosis (CF). The Flutter valve (Scandipharm, Birmingham, AL) has been introduced as an alternative method to CPT for airway mucus clearance. The objective of this study was to compare the short-term effects of CPT and the Flutter valve on pulmonary function and exercise tolerance in patients with cystic fibrosis. Twenty-three patients, 5 to 21 years of age, were randomized to receive one of two interventions: CPT or the Flutter valve, upon admission to the hospital for a 2-week treatment of pulmonary exacerbation. Pulmonary function testing (PFTs) and the 6-min walk test were performed on admission, day 7, and day 14 of hospitalization. Data analysis indicated no significant differences between the two groups on admission. Both groups showed improvement in pulmonary function test results, but the Flutter group had a higher mean forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV(1)) compared to the CPT group after 1 week of intervention. Both groups continued to improve during the 2-week intervention, with no significant difference in FVC or FEV(1) between groups by the end of 2 weeks. Mean forced expiratory flow rate between 25-75% of vital capacity (FEF(25-75)), 6-min walk distance, and resting arterial oxyhemoglobin saturation (SaO(2)) showed little change by day 7, but improved significantly (P< 0.05) by day 14 of hospitalization in both groups, with no significant difference between groups. This study demonstrated that patients using the Flutter device had better pulmonary function after 1 week of therapy and similar improvement in pulmonary function and exercise tolerance compared to CPT after 2 weeks of therapy, suggesting that Flutter valve therapy is an acceptable alternative to standard CPT during in-hospital care of patients with CF.

Isolated lower esophageal sphincter relaxation as "wave-suppressed" secondary peristalsis

Esophageal venting following air insufflation may occur by secondary peristalsis or by isolated transient lower esophageal sphincter relaxation (TLESR). To identify factors determining venting by these two mechanisms, we analyzed the responses to esophageal air insufflation in 4 infants and in 2 adults. We used a nine-lumen dual-Dent-sleeve manometric catheter with an air insufflation esophageal side hole, identifying swallowing by pharyngeal manometry or submental electromyography. The time from the venting lower esophageal sphincter relaxation (whether part of a secondary peristalsis or an isolated TLESR) to the next swallow (whether spontaneous, in the infants, or on command, in the adults) was characterized as > or = 15 sec or < 15 sec. Of the 25 evaluable trials, the subsequent swallow was > or = 15 sec after the venting response in 9 instances and < 15 sec afterward in 16 instances. Eight of the 9 trials with delayed swallows (> or = 15 sec) were vented by secondary peristalsis, whereas 11 of the 16 with early swallows (< 15 sec) were vented by TLESR (X2 p < 0.01). TLESRs may be induced by esophageal stimuli, in which case they may represent "wave-suppressed" secondary peristaltic complexes.

Airway function tests and vocal cord paralysis in lung transplant recipients

Maximum expiratory and inspiratory flow-volume (MEFV, MIFV) curves, specific airway conductance (sGaw), and flexible fiberoptic laryngoscopy were examined in 8 pediatric lung transplant recipients with vocal cord paralysis (VCP). Six were heart-lung (H-L) and 2 double-lung (D-L) recipients, 7 had left VCP, and 1 had right VCP. Based on the pulmonary function tests (PFT), 2 subgroups could be distinguished in the 8 recipients with VCP. Group A (5/8 recipients; mean age, 13 +/- 3.4 years; mean height, 144.3 +/- 12.3 cm) had significantly reduced specific airway conductance (sGaw; < 2 SD from predicted) and normal MEF25, MEF50, peak expiratory flow (PEF), forced expiratory volume in 1 second (FEV1), and %FEV1/forced vital capacity (FVC); this pattern suggested variable extrathoracic airway obstruction. PIF was normal in 4/5 and reduced in 1/5 of these recipients. Group B (3/8 recipients with VCP; mean age, 17 +/- 2.4 years; mean height, 156.3 +/- 12.0 cm) had significantly reduced sGaw, MEF25, MEF50, PEF, FEV1, and %FEV1/FVC, implying primarily small airway obstruction. These recipients had bronchiolitis obliterans. The results suggest that a pattern of reduced sGaw and normal MEFs, PEF, FEV1, and PIF should raise the possibility of VCP in patients after lung transplantation. sGaw is more sensitive than PIF and PEF in identifying airway obstruction due to VCP, and should be routinely included in the follow-up evaluation of lung transplant recipients.

Effects of anaerobic exercise on the immune system in eight- to seventeen-year-old trained and untrained boys

OBJECTIVES

To determine the immunologic response to a brief bout of intense exercise in children and to determine the effects of prolonged activity and maturation level of the subjects on this response.

STUDY DESIGN

We determined counts of leukocytes and their subsets, counts of lymphocytes and their subsets, and natural killer (NK) cell activity and cell number before and 3 and 60 minutes after a Wingate anaerobic test (WAnT) in 16 male swimmers (9 to 17 years of age) and 17 male nonswimmers (9 to 17 years of age). Subjects were also categorized by pubertal status based on Tanner staging and by level of physical activity. The Student t test and analysis of variance were used to determine statistical significance, with values expressed as mean +/- SEM.

RESULTS

Three minutes after the WAnT, all children had increases in leukocytes (28%), lymphocytes (43%), and NK cells (395%) (p < 0.01). Swimmers had less baseline NK cell activity (54 +/- 6 cytolytic units) than nonswimmers (87 +/- 10 cytolytic units) after the WAnT (p < 0.01), although both groups showed an increase to similar levels of NK activity 3 minutes after exercise. Pubertal effects on these responses were not significant.

CONCLUSIONS

Our results demonstrate transient leukocytosis, lymphocytosis, and increases in NK cell number and activity in 8- to 17-year-old boys after a brief bout of intense exercise. Formal athletic training appears to be associated with a lower baseline NK cell activity, and yet such activity is still within the normal range for this age group. Further investigations are necessary to determine the impact of such training on overall health and the ability to fight infection.

Development of the role-play inventory of situations and coping strategies for parents of children with cystic fibrosis

Critiqued previous conceptual and methodological approaches to the measurement of stress and coping. Applied Goldfried and D'Zurilla's behavior-analytic model to create a context-specific measure of problematic situations and coping strategies for parents of school-age children with cystic fibrosis (CF). The sample was stratified by child's gender and illness severity. Forty-seven families (46 mothers, 32 fathers) and 8 health care professionals completed structured interviews or daily diaries to obtain the widest range of problematic situations; 1,725 situations were elicited across all participants and then content-analyzed into 97 nonredundant categories in 11 domains (e.g., Discipline, Medical Care). Few differences were found in problem frequency or difficulty as a function of either gender or illness severity. Using empirical criteria, the most frequent and difficult problem situations were selected and developed into role-play vignettes that include relevant contextual, developmental, and interactional details. The Role-Play Inventory of Situations and Coping Strategies (RISCS) consists of 31 audiotaped vignettes designed to elicit and evaluate the coping strategies used by parents of children with CF.

Factors limiting anaerobic performance in adolescent males with cystic fibrosis

Forty-one adolescent males (11.1-18.3 yr) with cystic fibrosis (CF) and 37 healthy adolescent males (11.1-17.9 yr) performed a Wingate Anaerobic Test (WAnT). The group with CF was subdivided by sexual maturity, nutritional status, and degree of airway obstruction. The subjects with CF had lower absolute power outputs than the healthy controls [mean power in Watts (mean +/- SD): 350.2 +/- 135.9 vs 424.5 +/- 120.4, P < 0.001; peak power: 525.2 +/- 178.4 vs 665.9 +/- 191.3, P < 0.001). When absolute power was corrected for lean body mass, the subjects with CF had lower power outputs than the healthy controls (mean power in W.kg-1: 8.9 +/- 1.7 vs 9.6 +/- 0.9, P < 0.05; peak power: 13.4 +/- 2.1 vs 15.0 +/- 1.6, P < 0.05). The subgroup with CF with a higher body mass index (BMI > 17.5 kg.m-2) had higher peak and mean power output than subjects with CF with a lower BMI in both absolute power and when power was expressed per lean body mass. When sexual maturation was considered, subjects with CF with salivary testosterone greater than 4.0 ng.dl-1 had a higher mean and peak power in both absolute terms and relative to lean body mass than subjects with CF with salivary testosterone less than 4.0 ng.dl-1. Multiple regression analysis indicated that the nutritional factor accounted for 70%-80% of the variability in power output in the subjects with CF, while testosterone accounted for 10% of the variability. Pulmonary function was not a significant independent correlate of anaerobic power. Our results suggest that nutritional status, and to a lesser extent maturational factors, may play a more important role than pulmonary function in determining anaerobic fitness in male adolescents with CF.

Salivary testosterone levels in male adolescents with cystic fibrosis

PURPOSE

Salivary testosterone concentrations have been used for monitoring testosterone levels in male adolescents and have been found to correlate closely with serum values. Data are lacking on such measurements in male adolescents with cystic fibrosis (CF), in which salivary gland abnormalities are commonly seen. Delayed sexual maturation occurs in many patients with CF, particularly those with severe disease. We examined the usefulness of salivary testosterone collection and measurement in male adolescents with CF.

METHODS

Forty boys with CF and 35 healthy control boys participated in the study. All boys were Tanner staged and had serum and salivary testosterone concentrations measured. Testosterone assays were performed using standard radioimmunoassay techniques.

RESULTS

The boys with CF were slight older, lighter in body weight, and shorter. Serum and salivary testosterone concentrations were lower in the CF group than in the control group. A significant correlation was found between serum and salivary testosterone levels for boys with CF (r = .84) and for the control boys (r = .86). Mean salivary testosterone increased as age progressed and as Tanner stage advanced.

CONCLUSIONS

These results demonstrate that salivary testosterone measurements correlate well with serum values in male adolescents with CF and can be used in the monitoring of pubertal status.

Validity of self-assessment of sexual maturation in adolescent male patients with cystic fibrosis

PURPOSE

Self-assessment of sexual maturity by healthy male adolescents has been found to correlate closely with physician ratings. Data are lacking, however, in adolescents with cystic fibrosis (CF), where an altered body image may affect self-assessment. Delayed sexual maturation occurs in many patients with CF, particularly those with severe disease. We hypothesized that self-assessment of sexual maturation by adolescents with CF would agree with physician ratings.

METHODS

Using Tanner's standard photographs for pubic hair (PH) and genital (G) development, we compared self-assessment of sexual maturation to physician rating in 34 adolescent male patients with CF and 27 healthy male controls (C).

RESULTS

The two groups did not differ in age. All subjects were initially examined and Tanner-staged by a physician (SRB), and instructed in self-assessment using the Tanner photographs; they then performed a self-assessment. Scores by physician and subjects were assessed for inter-observer agreement by Kappa analysis. For the CF group, 29 of 34 PH assessments and 21 of 34 G assessments demonstrated exact inter-observer agreement between physician and subject ratings. The Kappa coefficient, kappa, (weighted for the degree of closeness between two observers) was 0.946 for PH and 0.840 for G and the C group, kappa was 0.905 for PH and 0.737 for G. Repeat analysis combining stages 3 and 4 PH and G development yielded higher inter-observer agreement in the CF group (33 of 34 PH assessments and 26 of 34 G assessments) and in the C group (24 of 27 PH assessments and 18 of 27 G assessments).

CONCLUSIONS

Self-assessment is a valid method to assess sexual maturity in clinical evaluation and as a research tool in the study of patients with CF.

Chronic pancreatitis in a patient with cystic fibrosis and clinical pancreatic insufficiency

Pancreatitis occurs in up to 15% of patients with cystic fibrosis and pancreatic sufficiency, but the possibility of its occurrence in patients with pancreatic insufficiency has not been recognized. We describe a patient with homozygous delta F508 cystic fibrosis and typical symptoms of pancreatic insufficiency (greasy, fatty stools) in whom pancreatitis developed.

Exercise testing in pediatric heart, heart-lung, and lung transplant recipients

Cardiorespiratory responses to progressive exercise were examined in 38 children who had undergone heart (n = 16), heart-lung (n = 13), or double-lung (n = 9) transplantation, and in 41 healthy controls. The four groups were similar in age, but the control subjects and heart transplant recipients were significantly larger than the heart-lung and lung recipients as assessed by body mass index (BMI). Time since transplant was significantly longer in the heart (601 days) compared with heart-lung (146 days) and lung (125 days) transplant groups. Physical work capacity and peak oxygen uptake were significantly reduced (43 to 64% of predicted) in the three transplant groups compared with the control group. Peak heart rate (percent predicted) was significantly higher in the control subjects (94%) compared with the heart (66%), heart-lung (70%), and lung (77%) transplant recipients. Peak minute ventilation was significantly higher in the control (72.9 L/min) and heart transplant (51.0 L/min) groups than the heart-lung (37.4 L/min) and lung (41.3 L/min) transplant groups. The control group had a higher peak tidal volume than the three transplant groups, and a higher peak respiratory rate than the lung transplant recipients. Correlational analysis revealed that physical work capacity (PWC) was significantly related to heart rate at peak exercise (HRpeak) and minute ventilation at peak exercise (VE-peak) in the heart transplant recipients, BMI, VEpeak, and FEV1 in the heart-lung transplant recipients, and BMI, HRpeak, VEpeak, FEV1, and number of days posttransplant in the lung transplant recipients. In addition to these variables, physical deconditioning and factors related to pharmacotherapy, infection, and rejection may also contribute to the decreased PWC observed in the transplant recipients.

Nutrition in the pediatric double lung transplant patient with cystic fibrosis

Cystic fibrosis (CF) is the most common lethal genetic disease in the white population. The pulmonary infections and pancreatic insufficiency make CF a medically challenging disease. Although the importance of nutrition in the CF patient is known, approximately 50% of CF patients are in less than the 10th percentile for weight and height as reported by the 1991 CF Foundation Registry of 114 CF Centers in the United States. This paper addresses the nutritional status of 10 pediatric CF patients who underwent double lung transplant at Children's Hospital of Pittsburgh between August 1991 and May 1993. Patients who survived beyond 1 year gained a significant amount of weight sooner after transplant than those who survived less than 1 year. Gastrostomy tube feedings were more effective than oral intake for weight gain after transplant. CF patients with pancreatic insufficiency have more difficulty with adjustment of doses of immunosuppressive agents for reasons that are not clearly understood.

Pseudomonas cepacia empyema necessitatis after lung transplantation in two patients with cystic fibrosis

Lung transplantation is an accepted modality for patients with cystic fibrosis (CF) who have end-stage respiratory failure. The postoperative course of these patients is often complicated by serious infections with organisms such as Pseudomonas aeruginosa and Pseudomonas cepacia that may be multiply resistant to conventional antimicrobial agents. We describe two patients with CF who, after double lung transplantation, developed the unusual complication of empyema and empyema necessitatis due to P cepacia that was resistant to all tested antibiotics.

Complications of pediatric lung and heart-lung transplantation

As more children receive lung and heart-lung transplants, understanding posttransplantation complications becomes more important. Complications can be categorized as 1) anatomic and surgical, 2) infectious, 3) rejection, 4) posttransplantation lymphoproliferative disease (PTLD), and 5) drug-related. In the early posttransplantation period, reimplantation injury and vascular obstruction with thrombus formation may occur, whereas stenosis at tracheal or bronchial anastomotic sites develops more slowly. Infections in the transplanted lung are common, and can be caused by bacteria, viruses, fungi, or protozoans. Both acute and chronic rejection are potentially serious. Frequent or severe episodes of acute rejection increase the risk of chronic rejection, characterized by obliterative bronchiolitis. Differentiating rejection from infection requires tissue, obtained through transbronchial or open lung biopsy. PTLD, related to Epstein-Barr virus infection, is common in children, and difficult to treat. Finally, drug toxicity from immunosuppressive agents causes considerable morbidity. Increased understanding will continue to improve the outcome for children undergoing lung and heart-lung transplantation.

Ear disease in children with cystic fibrosis

OBJECTIVE

To assess otitis media in children with cystic fibrosis.

DESIGN

Prospective prevalence survey.

SETTING

Otolaryngology and cystic fibrosis/pulmonology outpatient clinics, Children's Hospital of Pittsburgh (Pa), a regional referral center.

PATIENTS

Seventy patients, aged 4 months to 17 years, with documented cystic fibrosis who presented to the cystic fibrosis/pulmonary clinic with scheduled appointments were asked to volunteer for the study. The 70 patients recruited represent approximately one fourth of the children younger than 17 years with cystic fibrosis who were followed up by the cystic fibrosis/pulmonary clinic.

INTERVENTION

Ear, nose, and throat examination including pneumatic otoscopy, with tympanometry when indicated; relevant history taking.

MAIN OUTCOME MEASURE

Presence or absence of otitis media.

RESULTS

Seven (10%) of the 70 patients had unilateral or bilateral otitis media.

CONCLUSIONS

Children with cystic fibrosis have a low prevalence of otitis media compared with normal children.

Lipid levels in adults with cystic fibrosis

OBJECTIVE

To examine the hypothesis that an energy-dense, high-fat diet, which is necessary to maintain weight in adults with cystic fibrosis, does not result in high serum cholesterol levels.

DESIGN

Dietary, anthropometric, and biochemical data were correlated.

SETTING

A cystic fibrosis center in Pittsburgh, Pa.

SUBJECTS

Thirty-one adults with cystic fibrosis, 50 obligate carriers of the cystic fibrosis gene, and 26 controls who did not have cystic fibrosis.

MAIN OUTCOME MEASURES

Adults with cystic fibrosis had a lower mean serum cholesterol level and higher mean intakes of energy and fat than controls.

STATISTICAL ANALYSES PERFORMED

Student's t test was used to determine the statistical significance between two means. Univariate correlation coefficients were determined to measure the relative intensity of association between two variables.

RESULTS

Mean total serum cholesterol levels in men with cystic fibrosis was 3.1 mmol/L vs 4.7 mmol/L in male controls (P < .001). Mean total serum cholesterol levels in women with cystic fibrosis was 3.2 mmol/L vs 4.3 mmol/L in female controls (P < .001). Three adults with cystic fibrosis and no signs of pancreatic insufficiency had serum cholesterol levels in the high normal range. Carriers had serum lipid levels in the same range as the controls.

CONCLUSIONS/APPLICATIONS

The findings indicate that a high-energy, high-fat diet does not raise serum lipid levels in those patients with cystic fibrosis and pancreatic insufficiency. However, those individuals with cystic fibrosis and normal pancreatic function may be at the same risk as the general population for developing high serum lipid levels. They should have their serum lipid levels monitored and be given appropriate dietary recommendations.