The Prospective Assessment of Nutrition in Children with Cystic Fibrosis

Aims: Patients with Cystic Fibrosis (CF) have increased risk of malnutrition. Early detection of nutritional deterioration enables prompt intervention and correction. The aims of this project were to define the nutritional status of CF patients in Iran and New Zealand, compare and contrast the McDonald Nutritional Risk Screening (NRS) tool with the Australasian Guidelines for Nutrition in Cystic Fibrosis, and validate these results with each patient’s evaluation by their CF clinical team. Methods:Children with CF (2 - 18 years) were assessed during routine outpatient visits over one year. Anthropometric measurements were obtained. Both tools were applied and the results compared to their clinical evaluation (as gold standard) with calculation of specificity and sensitivity. Results:Under-nutrition was seen more frequent in the 33 Iranian children than in the 36 New Zealand (NZ) patients (39% versus 0%, p=0.0001), whereas over-nutrition was more prevalent in NZ children (9% versus 17%, p=0.05). At the first visit, both guidelines were able to recognize 77% and 61% of under-nourished Iranian patients, respectively. The mean sensitivity and specificity for all visits for the McDonald tool were 83% & 73% (Iran) and 65% & 86% (NZ). Sensitivity and specificity for the Australasian guidelines were 79% & 79% (Iran) and 70% & 90% (NZ). Conclusions: Both tools successfully recognised patients at risk of malnutrition. The McDonald tool had comparable sensitivity and specificity to that described previously, especially in Iranian patients. This tool may be helpful in recognizing at risk CF patients, particularlyin developing countries with fewer resources

2-Aminoacetophenone as a potential breath biomarker for Pseudomonas aeruginosa in the cystic fibrosis lung

<p>Abstract</p> <p>Background</p> <p><it>Pseudomonas aeruginosa </it>infections are associated with progressive life threatening decline of lung function in cystic fibrosis sufferers. Growth of <it>Ps. aeruginosa </it>releases a "grape-like" odour that has been identified as the microbial volatile organic compound 2-aminoacetophenone (2-AA).</p> <p>Methods</p> <p>We investigated 2-AA for its specificity to <it>Ps. aeruginosa </it>and its suitability as a potential breath biomarker of colonisation or infection by Solid Phase Micro Extraction and Gas Chromatography-Mass Spectrometry (GC/MS).</p> <p>Results</p> <p>Cultures of 20 clinical strains of <it>Ps. aeruginosa </it>but not other respiratory pathogens had high concentrations of 2-AA in the head space of <it>in vitro </it>cultures when analysed by GC/MS. 2-AA was stable for 6 hours in deactivated glass sampling bulbs but was not stable in Tedlar^®bags. Optimisation of GC/MS allowed detection levels of 2-AA to low pico mol/mol range in breath. The 2-AA was detected in a significantly higher proportion of subjects colonised with <it>Ps. aeruginosa </it>15/16 (93.7%) than both the healthy controls 5/17 (29%) (p < 0.0002) and CF patients not colonised with <it>Ps. aeruginosa </it>4/13(30.7%) (p < 0.001). The sensitivity and specificity of the 2-AA breath test compared to isolation of <it>Ps. aeruginosa </it>in sputum and/or BALF was 93.8% (95% CI, 67-99) and 69.2% (95% CI, 38-89) respectively. The peak integration values for 2-AA analysis in the breath samples were significantly higher in <it>Ps. aeruginosa </it>colonised subjects (median 242, range 0-1243) than the healthy controls (median 0, range 0-161; p < 0.001) and CF subjects not colonised with <it>Ps. aeruginosa </it>(median 0, range 0-287; p < 0.003)</p> <p>Conclusions</p> <p>Our results report 2-AA as a promising breath biomarker for the detection of <it>Ps. aeruginosa </it>infections in the cystic fibrosis lung.</p

Enhanced airway sensory nerve reactivity in non-eosinophilic asthma

BACKGROUND: Neural mechanisms may play an important role in non-eosinophilic asthma (NEA). This study compared airway sensory nerve reactivity, using capsaicin challenge, in eosinophilic asthma (EA) and NEA and non-asthmatics. METHODS: Thirty-eight asthmatics and 19 non-asthmatics (aged 14-21 years) underwent combined hypertonic saline challenge/sputum induction, fractional exhaled nitric oxide, atopy and spirometry tests, followed by capsaicin challenge. EA and NEA were defined using a sputum eosinophil cut-point of 2.5%. Airway hyperreactivity was defined as a ≥15% drop in FEV1 during saline challenge. Sensory nerve reactivity was defined as the lowest capsaicin concentration that evoked 5 (C5) coughs. RESULTS: Non-eosinophilic asthmatics (n=20) had heightened capsaicin sensitivity (lower C5) compared with non-asthmatics (n=19) (geometric mean C5: 58.3 µM, 95% CI 24.1 to 141.5 vs 193.6 µM, 82.2 to 456.0; p<0.05). NEA tended to also have greater capsaicin sensitivity than EA, with the difference in capsaicin sensitivity between NEA and EA being of similar magnitude (58.3 µM, 24.1 to 141.5 vs 191.0 µM, 70.9 to 514.0) to that observed between NEA and non-asthmatics; however, this did not reach statistical significance (p=0.07). FEV1 was significantly reduced from baseline following capsaicin inhalation in both asthmatics and non-asthmatics but no differences were found between subgroups. No associations with capsaicin sensitivity and atopy, sputum eosinophils, blood eosinophils, asthma control or treatment were observed. CONCLUSION: NEA, but not EA, showed enhanced capsaicin sensitivity compared with non-asthmatics. Sensory nerve reactivity may therefore play an important role in the pathophysiology of NEA

Time trends, ethnicity and risk factors for eczema in New Zealand children: ISAAC Phase Three.

BACKGROUND: Eczema is a common chronic disease which has significant morbidity and costs for children and their families. Phase One (1993) of the International Study of Asthma and Allergies in Childhood (ISAAC) found a high prevalence of symptoms of eczema in New Zealand. OBJECTIVE: In Phase Three (2001-3) we aimed to answer these three questions: Is the prevalence of eczema changing over time?; Are there ethnic differences in prevalence?; and What are the risk factors for eczema? METHODS: Five New Zealand centres participated in ISAAC Phases One and Three using the same methodology. Questionnaires about ethnicity, symptoms of eczema and environmental factors were completed by parents of 6-7 year olds (children) and self-completed by 13-14 year olds (adolescents). Prevalence and change per year were calculated by centre, ethnicity and gender. Prevalence differences between centres and associations with environmental factors were examined using logistic regression. RESULTS: There was little change in prevalence over time for the children, and a decrease in prevalence for the adolescents. Prevalence was higher among Māori and even higher among Pacific participants than among European children. Positive associations with current eczema symptoms were found for both age groups for truck traffic in the street of residence, and current paracetamol consumption, and for children only, antibiotics or paracetamol in the 1st year of life. Inverse associations were found with residence in New Zealand less than 5 years, consumption of milk, seafood, and eggs, and presence of a dog in the home. CONCLUSION: Eczema remains a significant problem, particularly for young Māori and Pacific New Zealanders in whom less recognition of eczema and poorer access to effective, sustained eczema management may be contributing factors. Reverse causation may explain all the environmental findings apart from truck traffic which is increasing in New Zealand

Tobacco or healthy children: the two cannot co-exist

Tobacco exposure increases mortality and morbidity of the fetus, the child, the adolescent, and their children in turn. Nearly half the children in the world are exposed. Smoking is not merely personal choice or personal responsibility; those subtle phrases undermine those who have no choice in the matter.Tobacco control must take a multi-pronged attack. Smoking cessation by adults in childbearing years must take centre stage of these efforts, because it is the only way to ensure a smoke-free environment for children. Smoke-free parents provide a role model for smoke-free young people, and erode the image of smoking as a desirable adult behaviour to emulate. Pediatricians and pediatric pulmonologists have a key role to play here. This goal will reduce morbidity and mortality among adults and children. Legislation regarding taxation, environments, tobacco constituents, product placement and display, packaging, and media education are all key to this core goal. Smokefree policy must be protected from attack based on trade agreements.Research is needed into more effective ways to attract and help people give up smoking, and into educating and re-deploying tobacco industry workers in emerging and developed countries

Adaptive resistance to tobramycin in Pseudomonas aeruginosa lung infection in cystic fibrosis

Aminoglycoside antibiotics have been shown to induce adaptive resistance in Pseudomonas aeruginosa in vitro and in a mouse model of infection, but adaptive resistance has not been described in human infections. Seven patients with cystic fibrosis were treated with inhaled tobramycin to determine whether adaptive resistance occurred in P. aeruginosa in their sputum. In three patients who had not recently taken antibiotics, 80 mg tobramycin was administered by nebuliser and resulting peak sputum tobramycin concentrations were 90-240 mg/L (elimination half-life 1.9-2.1 h). Adaptive resistance was detected in P. aeruginosa 1-4 h after the dose of tobramycin. Moderate resistance was present at 24 h and full susceptibility returned between 24 and 48 h. In four other patients on long-term twice-daily inhaled aminoglycoside treatment, adaptive resistance was present before, and 4 h after, 80 mg of tobramycin administered by nebuliser. The presence and time course of adaptive resistance in humans may have implications for improving aminoglycoside dosing regimens

Heart rate variability as a marker of autonomic nervous system activity in young people with eosinophilic and non-eosinophilic asthma.

OBJECTIVE: An imbalance in autonomic nervous system (ANS) activity may play a role in asthma, but it is unclear whether this is associated with specific pathophysiology. This study assessed ANS activity by measuring heart rate variability (HRV) in eosinophilic (EA) and non-eosinophilic asthma (NEA) and people without asthma. METHODS: HRV, combined hypertonic saline challenge/sputum induction, exhaled nitric oxide (FeNO), skin prick tests to measure atopy, and spirometry tests were conducted in teenagers and young adults (14-21 years) with (n = 96) and without (n = 72) generally well-controlled asthma. HRV parameters associated with sympathetic and parasympathetic ANS branches were analyzed. EA and NEA were defined using a 2.5% sputum eosinophil cut-point. Airway hyperreactivity (AHR) was defined as ≥15% reduction in FEV1 following saline challenge. RESULTS: HRV parameters did not differ between asthmatics and non-asthmatics or EA and NEA. They were also not associated with markers of inflammation, lung function or atopy. However, increased absolute low frequency (LFµs2; representing increased sympathetic nervous system (SNS) activity) was found in asthmatics who used β-agonist medication compared to those who did not (median: 1611, IQR 892-3036 vs 754, 565-1592; p < 0.05) and increased normalized low frequency (LF nu) was found in those with AHR compared to without AHR (64, 48-71 vs 53, 43-66; p < 0.05). CONCLUSION: ANS activity (as measured using HRV analysis) is not associated with pathophysiology or inflammatory phenotype in young asthmatics with generally well-controlled asthma. However, enhanced SNS activity can be detected in asthmatics with AHR or who use β-agonist medication

Has the prevalence and severity of symptoms of asthma changed among children in New Zealand? ISAAC Phase Three.

AIM: To investigate time trends in prevalence of symptoms of asthma by repeating, during 2001-3 (Phase Three), the International Study of Asthma and Allergies in Childhood (ISAAC) Phase One study that was conducted in New Zealand in 1992-3. METHODS: ISAAC Phase Three involved repeating the cross-sectional questionnaire survey of two age groups of school children (6-7 years and 13-14 years, children and adolescents respectively) using the same methodology as Phase One. In New Zealand it was conducted in Auckland, Bay of Plenty, Christchurch, Nelson, and Wellington. RESULTS: After 9 years, reported asthma ever increased from 24.6% to 30.2% in children and from 24.1% to 32.4% in adolescents (p<0.001). Current wheeze (written questionnaire) significantly decreased in children from 23.6% to 22.2% (p=0.002) and in adolescents from 29.7% to 26.7% (p=0.047), and for the video questionnaire from 18.1% to 11.1% (p<0.001). There was a significant reduction in wheezing limiting speech from 5.0% to 3.7% in children, and 7.9% to 6.2% in adolescents. Little regional variation was found. A higher proportion of children with asthma symptoms now report having ever had asthma. CONCLUSIONS: The decrease in prevalence and severity of symptoms of asthma is encouraging, but the reasons for these trends are currently unclear. Increases in asthma labelling are likely to be due to greater awareness of asthma. A trend of decreasing prevalence of asthma symptoms, if maintained, has positive implications for lessened burden of disease among asthmatics and lowered cost of treatment