Exposure to bile and gastric juice can impact the aerodigestive microbiome in people with cystic fibrosis.

Studies of microbiota reveal inter-relationships between the microbiomes of the gut and lungs. This relationship may influence the progression of lung disease, particularly in patients with cystic fibrosis (CF), who often experience extraoesophageal reflux (EOR). Despite identifying this relationship, it is not well characterised. Our hypothesis is that the gastric and lung microbiomes in CF are related, with the potential for aerodigestive pathophysiology. We evaluated gastric and sputum bacterial communities by culture and 16S rRNA gene sequencing in 13 CF patients. Impacts of varying levels of bile acids, pepsin and pH on patient isolates of Pseudomonas aeruginosa (Pa) were evaluated. Clonally related strains of Pa and NTM were identified in gastric and sputum samples from patients with symptoms of EOR. Bacterial diversity was more pronounced in sputa compared to gastric juice. Gastric and lung bile and pepsin levels were associated with Pa biofilm formation. Analysis of the aerodigestive microbiomes of CF patients with negative sputa indicates that the gut can be a reservoir of Pa and NTM. This combined with the CF patient's symptoms of reflux and potential aspiration, highlights the possibility of communication between microorganisms of the gut and the lungs. This phenomenon merits further research.

Using a learning health system to understand the mismatch between medicines supply and actual medicines use among adults with cystic fibrosis.

BACKGROUND: Studies in separate cohorts suggest possible discrepancies between inhaled medicines supplied (median 50-60%) and medicines used (median 30-40%). We performed the first study that directly compares CF medicine supply against use to identify the cost of excess medicines supply. METHODS: This cross-sectional study included participants from 12 UK adult centres with ≥1 year of continuous adherence data from data-logging nebulisers. Medicine supply was measured as medication possession ratio (MPR) for a 1-year period from the first suitable supply date. Medicine use was measured as electronic data capture (EDC) adherence over the same period. The cost of excess medicines was calculated as whole excess box(es) supplied after accounting for the discrepancy between EDC adherence and MPR with 20% contingency. RESULTS: Among 275 participants, 133 (48.4%) were females and mean age was 30 years (95% CI 29-31 years). Median EDC adherence was 57% (IQR 23-86%), median MPR was 74% (IQR 46-96%) and the discrepancy between measures was median 14% (IQR 2-29%). Even with 20% contingency, mean potential cost of excess medicines was £1,124 (95% CI £855-1,394), ranging from £183 (95% CI £29-338) for EDC adherence ≥80% to £2,017 (95% CI £1,507-2,526) for EDC adherence <50%. CONCLUSIONS: This study provides a conservative estimate of excess inhaled medicines supply cost among adults with CF in the UK. The excess supply cost was highest among those with lowest EDC adherence, highlighting the importance of adherence support and supplying medicine according to actual use. MPR provides information about medicine supply but over-estimates actual medicine use.

The impact of COVID-19 shielding on the wellbeing, mental health and treatment adherence of adults with cystic fibrosis.

People with cystic fibrosis (CF) were advised to undertake 'shielding' at home during the COVID-19 pandemic to reduce their risk of infection. We studied the impact shielding had on their wellbeing, mental health (GAD-7 and PHQ-9 scores) and adherence to treatment. 63 (46%) of 137 people surveyed responded (19 anonymously; 44 gave their identity). Most (94%) adhered to shielding advice 'all the time/often' but many (76%) found this difficult with disruption of their routines, relationships and exercise habits. Treatment adherence rates were high and continued during COVID-19. Depression scores were low and remained stable. Clinically significant anxiety rates rose from 27% pre-COVID-19 to 54% during COVID-19 and seven patients requested a psychology consultation from this study. There is a need to monitor the wellbeing of people with CF during the ongoing COVID-19 pandemic.

Current status of fertility and family formation in men with cystic fibrosis.

Men with cystic fibrosis are nearly always infertile due to congenital bilateral absence of the vas deferens, but can undergo assisted reproduction. Ill health may influence reproductive choices. This paper reports data on fertility and family formation in CF including the use of assisted reproduction in a total cohort of 205 men (mean age 30.9, range 16.6-64.3 years) studied over a 10-year period. Overall 102 (49.5%) were single, 52 (25.7%) were married, 48 (23.3%) were in long-term heterosexual relationships, and 3 (1.5%) were in same-sex relationships. One (0.5%) was fertile naturally. In total, 30 children were born to 23 (11%) men by assisted reproduction: 4 used donor sperm and 19 had sperm retrieval and intracytoplasmic sperm injection (ICSI). Two men each adopted two children; 15 (7.3%) men were acting as step-fathers to 20 children from their partners' previous relationships. Overall 41 (20%) men had fatherhood roles. ICSI was unsuccessful in 4 men. A further 16 men were referred for fertility treatment but did not proceed. Of the 19 men having children by ICSI, 3 died leaving 4 children. Men with CF face complex decisions when considering their relationships, fertility and fatherhood.

Establishing a Pediatric Hematology-Oncology Program in Botswana.

PURPOSE: Annually, 300,000 children are diagnosed with cancer, and the majority of these children live in low- and middle-income countries (LMICs). Currently, there is incomplete information on pediatric cancer incidence, diagnosis distribution, and treatment outcomes in Africa. Since 2007, a pediatric hematology-oncology program has been operating in Botswana through a partnership between the Botswana government, Baylor College of Medicine, and Texas Children's Hospital. METHODS: To better understand patient characteristics and outcomes at Botswana's only pediatric cancer program, a hospital-based data base-the Botswana Pediatric Oncology Database-was established in 2014. Children younger than 18 years of age at the time of diagnosis who presented between 2008 and 2015 were included. Data for this study were extracted in February 2016. RESULTS: Of the 240 potential enrollees, 185 (77%) children met eligibility for this study. The median age was 6.4 years, and 50.8% were male. Leukemia was the most common malignancy representing 18.9% of the cohort and 88.1% of the total cohort had a histopathologic diagnosis. HIV seropositivity was confirmed in 13.5%. The 2-year overall survival of all pediatric cancer diagnoses was 52.4%. Abandonment of treatment occurred in 3.8% of patients. CONCLUSION: In the first 9 years of the program, capacity has been developed through a longstanding partnership between Botswana and Baylor College of Medicine/Texas Children's Hospital that has led to children receiving care for cancer and blood disorders. Although continued improvements are necessary, outcomes to date indicate that children with cancer in Botswana can be successfully diagnosed and treated.

Successful management of congenital/infantile fibrosarcoma presenting as large, non-healing buttock ulceration.

A two-year-old boy presented with a large, non-healing ulceration on his left buttock, which was originally noted as a brown patch present at birth. Punch skin biopsy was performed and histopathology revealed an atypical, pleomorphic, spindled proliferation in whorled fascicles replacing the dermis and trapping fat in the subcutis, consistent with a diagnosis of congenital/infantile fibrosarcoma. No evidence of metastatic spread was seen on imaging. The tumor was initially deemed unresectable owing to extent of local invasion. Neo-adjuvant chemotherapy caused significant tumor shrinkage and the patient underwent complete resection.

Current characteristics, challenges and coping strategies of young people with cystic fibrosis as they transition to adulthood.

This study provides detailed data on the current characteristics, perceptions and outcomes of 45 young people with cystic fibrosis (CF) as they transition into adulthood. Although many had severe disease, they generally coped well, found attendance at a transition clinic helpful and welcomed the increased independence of an adult healthcare environment. Levels of psychological distress were low with only 15.6% having anxiety and 6.7% depression. The main psychological coping strategy used was optimistic acceptance. Overall, most remained stable after transfer but 33% had some decline in lung function and 9% in nutritional status, requiring intensification of treatment. They had high levels of satisfaction with their relationships and life situations and 76% were in employment or education. These results are encouraging and as life expectancy improves, young adults with CF are coping well with transition into adulthood.

Travelling abroad with cystic fibrosis: Assessment of risks and healthcare requirements.

There is limited information on the risks and healthcare requirements of patients with cystic fibrosis (CF) undertaking travel abroad. Of 100 patients (mean age 24.7 years, mean FEV1 57.3 %predicted) attending a UK adult CF Centre, 96% had travelled abroad but 14% now limited travel on medical advice. They travelled frequently and widely, often undertaking adventurous activities on holidays, but because of the costs involved, 18% travelled without travel insurance and 23% with insurance which did not cover CF. Of those who had ever had an illness abroad 10% had a CF-related illness (7 chest infection, 2 dehydration, 1 pancreatitis) and 12% a non-CF-related illness (4 sunburn, 3 gastroenteritis, 3 ear infection, 1 fall, 1 gastro-oesophageal reflux). There is a wide range of disease severity and assessment of the medical risks and the travel insurance premium to be charged should be based on the individual's health status rather than generically on the basis of a diagnosis of CF.

Ivacaftor and symptoms of extra-oesophageal reflux in patients with cystic fibrosis and G551D mutation.

BACKGROUND: Extra-oesophageal reflux (EOR) may lead to microaspiration in patients with cystic fibrosis (CF), a probable cause of deteriorating lung function. Successful clinical trials of ivacaftor highlight opportunities to understand EOR in a real world study. METHODS: Data from 12 patients with CF and the G551D mutation prescribed ivacaftor (150mg bd) was collected at baseline, 6, 26 and 52weeks. The changes in symptoms of EOR were assessed by questionnaire (reflux symptom index (RSI) and Hull airway reflux questionnaire (HARQ)). RESULTS: Six patients presented EOR at baseline (RSI >13; median 13; range 2-29) and 5 presented airway reflux (HARQ >13; median 12; range 3 to 33). Treatment with ivacaftor was associated with a significant reduction of EOR symptoms (P<0∙04 versus baseline) denoted by the reflux symptom index and Hull airway reflux questionnaire. CONCLUSION: Ivacaftor treatment was beneficial for patients with symptoms of EOR, thought to be a precursor to microaspiration.

Cryptogenic Cirrhosis and Hepatopulmonary Syndrome in a Boy with Hepatic Hemangioma in Botswana: A Case Report and Review of the Literature.

Hepatic hemangiomas are considered to be the most common benign tumors of the liver. They are often found incidentally while investigating for other causes of liver disease. Hemangiomas that are less than 10 cm are not expected to cause any problems. Typically, they do not enlarge and, apart from regular follow-up, no definitive treatment is indicated. This is a posthumous case report of a male child with a medium-sized hemangioma from infancy, complicated by cryptogenic cirrhosis and hepatopulmonary syndrome. It demonstrates the challenges of managing a child with such complicated conditions in a resource-limited setting.

A service evaluation of an integrated model of palliative care of cystic fibrosis.

BACKGROUND: Patients with advanced cystic fibrosis have severe symptoms with a complex trajectory of exacerbations and recovery. They are often awaiting lung transplantation, and many die without receiving specialist palliative care. AIM: We introduced an integrated model whereby palliative specialists joined the cystic fibrosis team to provide palliative care in parallel with standard care. DESIGN: A service evaluation of this model of care was undertaken in a prospective case series documenting symptoms and outcomes, the views of the cystic fibrosis team and the experience of the palliative specialists. SETTING/PARTICIPANTS: Over 3 years, 28 (10%) of 282 patients attending the cystic fibrosis centre had specialist palliative care. RESULTS: They had advanced lung disease (mean forced expiratory volume in 1 s (FEV1) = 0.86 L (25% predicted)), and 17 died: 6 were on a transplant waiting list at death; 10 were unsuitable and 1 died post transplantation. All who died over these 3 years had specialist palliative care. Four patients had successful transplants. Assessment showed a high prevalence of breathlessness, cough, pain, vomiting and fatigue, with a significant impact on daily life. The cystic fibrosis team rated this model of care highly, felt that palliative care should be members of the team, and thought that patients had found it helpful. The palliative specialists gained knowledge of cystic fibrosis, found it beneficial to meet patients earlier in the disease, and identified unmet needs in managing bereavement and the effects of deaths on other patients with cystic fibrosis. CONCLUSION: This model has been successful in overcoming the difficulties in access to specialist palliative care for patients with cystic fibrosis.

Class I and II HLA antibodies in pediatric patients with thalassemia major.

BACKGROUND: HLA alloimmunization is a potential complication of red blood cell (RBC) transfusion with detrimental consequences for future organ or hematopoietic stem cell transplantation. STUDY DESIGN AND METHODS: The study aimed to determine the prevalence and specificity of HLA antibodies among pediatric patients with thalassemia major (TM) and antibody changes over time while on leukoreduced chronic transfusion therapy. HLA antibodies were measured at two or more time points in children and young adults ages 3 to 21 years with TM. HLA Class I and II antibodies were measured by FlowPRA screening. Positive screening assays were confirmed with LabScreen single-antigen bead assays for antibody specificity. RESULTS: HLA antibodies were detected in 10 of 19 (53%) subjects: seven of 19 (37%) with HLA Class I and II antibodies, two of 19 (11%) with only HLA Class I antibodies, and one of 19 (5%) with only HLA Class II antibodies. Subjects with HLA antibodies were older (14.6 years vs. 7.1 years, p = 0.05), predominantly male (80%), and more likely to have a remote history of nonleukoreduced transfusions (p = 0.057). Median time between testing was 3.7 years. De novo HLA antibodies were detected in two of 11 patients who initially had negative panel-reactive antibody screens, while one subject lost detection of Class II antibody. Two of seven patients with HLA antibodies had antibodies to self-HLA. CONCLUSION: HLA antibodies have a high prevalence in TM patients and may be associated with nonleukoreduced transfusions and older age. For such patients, antibody identification will be useful if subsequent organ or stem cell transplantation is needed.

Growth of the microalgae Tetraselmis tetrathele and nitrate depletion in culture medium Guillard f/2 and Conway / Crescimento da microalga Tetraselmis tetrathele e depleção de nitrato em meio de cultivo Guillard f/2 e Conway

This study aimed to evaluate the effect of nutrient depletion during the cultivation of the microalgae Tetraselmis tetrathele, and to verify the algal growth and productivity in different culture media (Guillard f/2 and Conway). The experiment was conducted in nine-liter containers, with working volume of eight liters, salinity 35 ± 2‰, temperature 28 ± 1°C, with constant light and aeration, around 200 µE cm-2 s-1 and 3 L air min.-1. Results showed that microalgae development caused nutrient depletion, since we observed an inversely proportional relationship between nitrate concentration and algal biomass during the cultivation. Regarding the culture media, a higher algal productivity was observed in the cultivation developed in Conway medium (p < 0.05), obtaining at the end of the cultivation, biomass of 3.38 ± 0.02 g L-1. In the Guillard medium, only 2.47 ± 0.05 g L-1 was obtained. The cultivation in Conway medium presented better results concerning microalgae growth, with a more pronounced exponential phase. This was due to the higher nitrate availability, which was reduced more rapidly in the culture medium Guillard f/2.

O presente trabalho teve como objetivo avaliar o efeito da depleção de nutrientes durante o cultivo da microalga Tetraselmis tetrathele, bem como verificar o crescimento e a produtividade algal em diferentes meios de cultivo (Guillard f/2 e Conway). O experimento foi realizado em recipientes de nove litros, com volume útil de oito litros, salinidade de 35 ± 2‰, temperatura de 28 ± 1°C, com iluminação e aeração constantes, em torno de 200 µE cm-2 s-1 e 3 L ar min.-1. Os resultados mostraram que o desenvolvimento da microalga resultou na depleção de nutrientes, uma vez que foi observada uma relação inversamente proporcional entre a concentração de nitrato e a biomassa algal durante o cultivo. Em relação aos meios de cultivo, foi observada maior produtividade algal na cultura desenvolvida em meio Conway (p < 0,05), obtendo, ao final do cultivo, biomassa de 3,38 ± 0,02 g L-1. No meio Guillard foi obtido apenas 2,47 ± 0,05 g L-1. O cultivo em meio Conway apresentou resultados melhores quanto ao crescimento microalgal, dispondo de uma fase exponencial mais acentuada. Isto por conta da maior disponibilidade do nitrato, o qual foi reduzido mais rapidamente no cultivo em meio Guillard f/2.

HLA alloimmunization is associated with RBC antibodies in multiply transfused patients with sickle cell disease.

BACKGROUND: Alloimmunization to minor red blood cell (RBC) antigens occurs commonly in sickle cell disease (SCD). Patients with alloimmunization demonstrate increased risk for new alloantibody formation with subsequent transfusion. Alloimmunization to human leukocyte antigens (HLA) can occur with RBC transfusion and may result in graft rejection during stem cell or organ transplantation. The prevalence and risk factors for HLA alloimmunization in multiply transfused pediatric SCD patients are unknown. PROCEDURE: A cross-sectional study of HLA alloimmunization in SCD patients aged 3-21 years with a history of >or=3 RBC transfusions was performed to test the hypothesis that HLA alloimmunization is associated with RBC alloimmunization. Antibodies to class I and class II HLA were measured by Flow Panel Reactive Antibody (FlowPRA). RESULTS: Seventy-three SCD patients (30 with RBC antibodies) were tested. HLA antibodies were detected in 25/73 (34%) patients; class I HLA antibodies occurred in 24/73 (33%) and class II HLA antibodies occurred in 3 (4%). Among patients with RBC antibodies, 16/30 (53%) had HLA antibodies, while 9/43 (21%) patients without RBC antibodies had HLA antibodies (OR 4.32 [1.6-12.1]). In a multivariate analysis, antibodies to RBC antigens were an independent predictor of HLA alloimmunization (P = 0.041). The association of RBC and HLA immunization was strongest among patients with no history of chronic transfusion therapy. CONCLUSIONS: This analysis is the first description of HLA alloimmunization in pediatric SCD patients who receive primarily leukoreduced RBC transfusions and demonstrates that HLA alloimmunization tendency is associated with antibodies to RBC antigens.

Werner's syndrome helicase participates in transcription of phenobarbital-inducible CYP2B genes in rat and mouse liver.

Werner's syndrome (WS) is a rare human autosomal recessive segmental progeroid syndrome clinically characterized by atherosclerosis, cancer, osteoporosis, type 2 diabetes mellitus and ocular cataracts. The WRN gene codes for a RecQ helicase which is present in many tissues. Although the exact functions of the WRN protein remain unclear, accumulating evidence suggests that it participates in DNA repair, replication, recombination and telomere maintenance. It has also been proposed that WRN participates in RNA polymerase II-dependent transcription. However no promoter directly targeted by WRN has yet been identified. In this work, we report mammalian genes that are WRN targets. The rat CYP2B2 gene and its closely related mouse homolog, Cyp2b10, are both strongly induced in liver by phenobarbital. We found that there is phenobarbital-dependent recruitment of WRN to the promoter of the CYP2B2 gene as demonstrated by chromatin immunoprecipitation analysis. Mice homozygous for a Wrn mutation deleting part of the helicase domain showed a decrease in basal and phenobarbital-induced CYP2B10 mRNA levels compared to wild type animals. The phenobarbital-induced level of CYP2B10 protein was also reduced in the mutant mice. Electrophoretic mobility shift assays showed that WRN can participate in the formation of a complex with a specific sequence within the CYP2B2 basal promoter. Hence, there is a WRN binding site in a region of DNA sequence to which WRN is recruited in vivo. Taken together, these results suggest that WRN participates in transcription of CYP2B genes in liver and identifies the first physical interaction between a specific promoter sequence and WRN.

Transfusion management of sickle cell patients during bone marrow transplantation with matched sibling donor.

BACKGROUND: Sickle cell disease (SCD) patients have unique transfusion considerations during bone marrow transplantation (BMT), including prophylaxis against stroke and alloimmunization. Characterization of transfusion requirements is important for blood bank and clinician patient management. STUDY DESIGN AND METHODS: A retrospective analysis of red blood cell (RBC) and platelet (PLT) transfusion of SCD patients during myeloablative matched sibling donor (MSD) BMT at one institution from 1993 to 2007 was performed. Patient characteristics (RBC blood group antibodies, ABO-incompatible donor, BMT-related morbidity) and transfusion practices (RBC phenotype matching, transfusion threshold, and blood age) were assessed for effect on total RBC transfusion volumes. RESULTS: Twenty-seven patients received MSD BMT with 96% survival and 0% rejection. Six alloimmunized patients received RBCs with extended phenotype matching (C, c, E, e, K, Fy(a), Jk(b)), 14 nonalloimmunized received limited matching (C, c, E, e, K), and 7 did not have phenotype matching. Among 26 survivors, a median seven RBC transfusions (range, 3-15) and 13.5 PLT transfusions (range, 4-48) per patient were administered, equivalent to 64 mL/kg RBCs (range, 22-122 mL/kg) and 106 mL/kg PLTs (range, 26-343 mL/kg). BMT-related morbidity predicted increased RBC transfusions (p = 0.006). Venoocclusive disease was associated with greater RBC (p = 0.016) and PLT transfusion volumes (p = 0.016). Greater phenotype matching was associated with decreased RBC transfusions (p = 0.0247). CONCLUSIONS: SCD patients have high transfusion support during MSD BMT. Communication of BMT complications to the blood bank is essential for transfusion inventory management. Phenotype matching decreased RBC transfusions in this cohort and warrants further investigation in SCD transfusion therapy.

Dexamethasone induction of murine CYP2B genes requires the glucocorticoid receptor.

Hepatic cytochrome P450 (P450) enzymes metabolize exogenous and endogenous compounds, and many are inducible by xenobiotics. Their synthesis is tightly regulated, particularly through nuclear receptors. Expression of murine CYP2B genes is strongly activated by treatment with phenobarbital or phenobarbital-like inducers, and a detectable response requires the presence of the constitutive androstane receptor (CAR). However, other compounds can also induce murine CYP2B proteins. For example, dexamethasone is known to induce rat CYP2B1 and CYP2B2 and mouse CYP2B10. Using human HepG2 and rat H4IIEC3 hepatoma cell lines, we found that dexamethasone induction of CYP2B2 and Cyp2b10 luciferase reporters required the glucocorticoid receptor. Given the well known observation that CYP2B genes are not phenobarbital-responsive in cultured cell lines, the dexamethasone responsiveness of CYP2B reporter constructs in cell lines demonstrates in itself that the mechanism of dexamethasone induction is distinct from that of phenobarbital. We also analyzed the relative importance of the phenobarbital response unit (PBRU) and of a known glucocorticoid response element in this response. Both sites contributed to the response, but other sites were required for maximal induction. CAR was also found to act as an accessory factor to stimulate the response to dexamethasone by the glucocorticoid receptor. Furthermore, in H4IIEC3 cells, CAR activated the PBRU in the natural sequence context of the CYP2B2 and Cyp2b10 5' flanks. In summary, there are at least two independent mechanisms of CYP2B induction: one involving phenobarbital and phenobarbital-like inducers and another involving glucocorticoids that induce via the glucocorticoid receptor with CAR acting as an accessory factor.

Efficacy of laparoscopic cholecystectomy in the pediatric population.

PURPOSE: Gallbladder disease is increasingly affecting the pediatric population. The advent of new technology in the 1980s, specifically, hepatobiliary scintigraphy and laparoscopic cholecystectomy, gave a dramatic rise in both the diagnosis and treatment of biliary disease in the pediatric population. The purpose of this study was to determine (a) whether laparoscopic cholecystectomy for biliary dyskinesia is efficacious in the treatment of children with biliary colic and (b) the ability of cholescintigraphy to predict which patients may benefit from an operative intervention. METHODS: We performed a retrospective review of the records of all patients (N = 184) who underwent laparoscopic cholecystectomy, correlating postoperative results with degree of dyskinesia (percentage of ejection fraction), histopathology, associated gastrointestinal diagnoses, age, and sex. Biliary dyskinesia was defined by ultrasonography without evidence of cholelithiasis with clinical diagnosis of biliary colic. RESULTS: Of the 184 patients who underwent laparoscopic cholecystectomy, 117 had a diagnosis of biliary dyskinesia and 108 were available for follow-up. Mean follow-up was 8.3 months. One hundred patients (92.6%) reported resolution or improvement of preoperative symptoms (64.8% reported complete resolution and 27.8% reported improvement in symptoms). The mean age of the patients was 14.1 years. No correlation was seen for degree of dyskinesia, histopathology, age, and sex. Patients with a preoperative diagnosis of gastroesophageal reflux were more likely to report resolution of symptoms, although this finding was not statistically significant. There was no major complication; 1 patient suffered a prolonged ileus, 1 patient suffered a wound infection, and 1 patient required incisional hernia repair. CONCLUSION: Laparoscopic cholecystectomy is safe, efficacious, and durable in children suffering from biliary dyskinesia.