Azithromycin for cystic fibrosis.

During what is a relatively barren time for new therapies for cystic fibrosis (CF), azithromycin has received a lot of attention as a potential treatment for CF lung disease. Laboratory studies suggest that azithromycin may have indirect actions, including anti-inflammatory, in addition to the standard antibacterial properties. The unique pharmacokinetics of azithromycin sets it aside from other macrolide antibiotics, but may result in increased resistance patterns. Three well-designed randomised controlled trials have demonstrated a small but significant improvement in respiratory function (forced expiratory volume in one second) with azithromycin compared with placebo. These trial results are confirmed by a recent meta-analysis. Mild adverse events (wheeze, diarrhoea and nausea) were significantly increased in one trial. There is no clear consensus regarding the correct dose and length of treatment with azithromycin. The present review discusses the role of azithromycin in the management of cystic fibrosis and the need for close monitoring of patients started on this drug. In addition, clinics should liaise closely with their microbiology departments and monitor resistance patterns.

Primary pulmonary lymphangiectasia in infancy and childhood.

Primary pulmonary lymphangiectasia (PPL) is a rare disorder of unknown aetiology characterised by dilatation of the pulmonary lymphatics. PPL is widely reported to have a poor prognosis in the neonatal period and little is known about the clinical features of patients who survive the newborn period. The current authors report the outcome in nine patients diagnosed in infancy with PPL over a 15-yr period at a single university-based hospital clinic and followed for a median of 6 yrs. Although all of the patients initially experienced respiratory distress, respiratory symptoms improved in most patients after infancy and were notably better by the age of 6 yrs. Many patients had poor weight gain in the first years of life, which eventually improved. Radiological scans showed progressive resolution of neonatal infiltrates, but were characterised by hyperinflation and increased interstitial markings in older children. Most patients had evidence of bronchitis and grew pathogenic organisms from quantitative bronchoalveolar lavage culture. Pulmonary function tests showed predominantly obstructive disease that did not deteriorate over time. In conclusion, these results suggest that primary pulmonary lymphangiectasia does not have as dismal a prognosis as previously described and symptoms and clinical findings improve after the first year of life.

Macrolide antibiotics for cystic fibrosis.

BACKGROUND: Chronic severe infection with Pseudomonas aeruginosa, affects many people with cystic fibrosis (CF). There is evidence from the laboratory and from other disease processes that macrolide antibiotics, whilst not directly active against Pseudomonas aeruginosa, may have indirect actions against this organism. OBJECTIVES: We aimed to test the hypotheses that, in people with CF, macrolide antibiotics:(1) improve clinical status compared to placebo or another antibiotic;(2) do not have unacceptable adverse effects. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture macrolide antibiotics for unpublished or follow-up data (December 2003). Most recent search of the Group's register: January 2004 SELECTION CRITERIA: Published or unpublished randomised controlled trials of macrolide antibiotics compared to placebo, another class of antibiotic or another macrolide antibiotic. Studies comparing regimens of the same macrolide antibiotic at different doses will also be included. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. Three groups were contacted for missing data and we hope to include these in future reviews. MAIN RESULTS: Searches identified 14 studies, four were included in this review (296 participants). Two studies enrolled adults, one children (a significant number of whom were not colonised with Pseudomonas aeruginosa) and one both adults and children. All the clinical studies reported small but significant improvements in respiratory function with azithromycin versus placebo. Meta-analysis at the one-month and six-month time points demonstrates a significant benefit with respect to relative change in FEV1 (at six months, for n = 104, azithromycin and n = 114, placebo; WMD 5.82% (95% CI 2.45 to 9.20)). The largest study reported a significant increase in mild adverse events (nausea, diarrhoea and wheezing). REVIEWERS' CONCLUSIONS: There is clear evidence from these studies of a small but significant improvement in respiratory function following treatment with azithromycin. The largest study employed a three times a week dose and, in this study, treatment with azithromycin was associated with a significant increase in mild adverse events. Further studies are needed to clarify the precise role of azithromycin in the treatment of CF lung disease.

Macrolide antibiotics for cystic fibrosis.

BACKGROUND: The antibiotic treatment of chest infections which characterise cystic fibrosis (CF) has significantly improved prospects for people with CF. The nature of organisms causing these infections has restricted antibiotic choice. Pseudomonas aeruginosa, especially, is resistant to most oral antibiotics. There is evidence from the laboratory and from other disease processes that macrolide antibiotics, whilst not directly active against Pseudomonas aeruginosa, may have indirect actions against this organism. OBJECTIVES: We aimed to test the hypotheses that macrolide antibiotics:(1) improve clinical status compared to placebo or another antibiotic;(2) have no unacceptable adverse effects. If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings.We contacted principal investigators known to work in the field, previous authors and pharmaceutical companies who manufacture macrolide antibiotics for unpublished or follow-up data (December 2002). Date of the most recent search of the Group's register: March 2003. SELECTION CRITERIA: Published or unpublished randomised controlled trials of macrolide antibiotics compared to placebo, another class of antibiotic or another macrolide antibiotic. Studies comparing regimens of the same macrolide antibiotic at different doses will also be included. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. Two groups were contacted for missing data, but these were unavailable for the review. MAIN RESULTS: Searches identified eleven studies, two were included in this review (101 participants). One study enrolled adults and the other children (a significant number of whom were not colonised with Pseudomonas aeruginosa). Both studies report small but significant changes in respiratory function (% change in FEV1) in favour of azithromycin. Meta-analysis at the two-month time point demonstrated a significant benefit with respect to percentage change in FVC (weighted mean difference 5.42 (1.77 to 9.07)) from azithromycin, but no difference with respect to percentage change of FEV1. There were no significant adverse effects reported. REVIEWER'S CONCLUSIONS: The role of macrolides in the management of CF lung disease remains unclear and there are many unanswered questions. Two small randomised controlled trials have suggested short-term improvement in respiratory function with azithromycin. Until the results of further studies are available the widespread use of azithromycin in CF cannot be advocated and should be restricted to well-designed randomised controlled trials.

The presentation and management of juvenile-onset chronic inflammatory bowel disease in Northeastern Scotland.

PURPOSE: This study reviews the presentation and management of juvenile onset chronic inflammatory bowel disease and identifies changes in incidence of the disease over a 20-year period. METHODS: This was a retrospective study of all patients aged 16 and under with chronic inflammatory bowel disease diagnosed in 1 health region between 1980 and 1999. The patients were identified from computer records and the following variables studied: age, sex, mode of presentation, medical and surgical management, and length of follow-up. RESULTS: One hundred seven patients were identified: 77 with Crohn's disease and 30 with ulcerative colitis. The incidence of ulcerative colitis and Crohn's disease has risen from 0.7 in 100,000 and 2.2 in 100,000, respectively, in the years 1980 through 1989 to 1.5 in 100,000 and 4.4 in 100,000 in the period 1990 through 1999. The median age at presentation was 10.1 years for ulcerative colitis and 10.8 years for Crohn's disease. The majority of disease was diagnosed within 1 year of the onset of symptoms, which were principally abdominal pain, diarrhea, and rectal bleeding. The average length of follow-up was 6.9 years. Analysis of the surgical management of Crohn's patients has shown a low rate of surgical intervention. CONCLUSIONS: This study has shown an increasing incidence of chronic inflammatory bowel disease in the Grampian region of Scotland coupled with a low rate of surgical intervention in Crohn's disease. These findings could be the result of early referral and diagnosis, with the disease being documented earlier in its course or more aggressive preemptive medical therapy.

Survival following Burkholderia cepacia sepsis in a patient with cystic fibrosis treated with corticosteroids.

We describe an 11-year-old girl with cystic fibrosis (CF) who presented with respiratory failure and Burkholderia cepacia bacteremia (cepacia syndrome). She survived her illness after aggressive treatment with parenteral antibiotics and corticosteroids. We speculate that treatment with corticosteroids may decrease the influx of proinflammatory cytokines and neutrophil-induced inflammation, with resulting improvement in the outcome of cepacia syndrome in CF patients.

A modified technique for measurement of nasal transepithelial potential difference in infants.

OBJECTIVE: To establish a method for measuring nasal transepithelial potential difference (PD) in infants. STUDY DESIGN: A modified infant method (smaller catheter size, reduced flow rates, and shorter protocol time) was compared with an established adult nasal PD method in 10 adult volunteers (4 with cystic fibrosis [CF]). Nasal PD was measured in 13 infants with a possible diagnosis of CF. RESULTS: Recordings were similar for the established and the modified methods in adult volunteers. An amiloride concentration of 10(-4) mol/L was necessary for full inhibition of amiloride-sensitive sodium ion (Na(+)) transport. Of the 13 infants, 2 had PD values suggestive of CF (mean baseline PD, -50.1 mV and -31.4 mV; maximum baseline PD, -61 mV and -49 mV; change in PD after perfusion with zero chloride solution with isoprenaline and amiloride [DeltazeroCl(-)/Iso], -1 mV and +3.5 mV), and 11 had normal values (mean +/- SEM baseline PD, -13.2 +/- 1.0 mV; maximum baseline PD, -21.4 +/- 2.0; DeltazeroCl(-)/Iso, -15.3 +/- 1.9 mV). These results correlated with subsequent sweat test data, mutation analysis, and clinical outcome. CONCLUSION: Nasal PD measured with this modified method is comparable to that measured with an established adult method. The measurements were well tolerated in 13 infants and discriminated bioelectric profiles characteristic of normal and CF respiratory epithelium. This study supports the use of this modified nasal PD technique as a diagnostic test for CF in newborn infants.

Liquid and ion transport by fetal airway and lung epithelia of mice deficient in sodium-potassium-2-chloride transporter.

Chloride (Cl(-)) movement across fetal lung epithelia is thought to be mediated by the sodium-potassium-2-Cl(-) cotransporter NKCC1. We studied the role of NKCC1 in Cl(-) and liquid secretion in late-gestation NKCC-null (-/-) and littermate control fetal mouse lung. NKCC -/- mice had decreased lung water compared with littermate controls (wet/dry: control, 8.01 +/- 0.09; NKCC -/-, 7.06 +/- 0.14). Liquid secretion by 17-d NKCC -/- distal lung explants was similar to control explants. Bumetanide inhibited basal liquid secretion in control but not NKCC -/- explants (expansion over 48 h: control, 35 +/- 4%; NKCC -/- 46 +/- 7%). Treatment with 4,4'-diisothiocyanto-stilbene-2,2'-disulfonic acid (DIDS) decreased liquid secretion in both control and NKCC -/- explants. Basal transepithelial potential difference (PD) of control tracheal explants was higher than that of NKCC -/- (control, -13.7 +/- 0.5 mV; NKCC -/-, -11.6 +/- 0.6 mV). Amiloride (10(-)(4) M) inhibited basal PD to the same extent in control and NKCC -/- mice. Terbutaline-stimulated hyperpolarization was less in NKCC -/- than in control tracheas (DeltaPD: control, -10.8 +/- 1.33 mV; NKCC -/-, -6.1 +/- 0.7 mV) and was inhibited by DIDS and acetazolamide in NKCC -/- but not wild-type explants. We conclude that NKCC is rate-limiting for transcellular Cl(-) transport, and that alternative anion transport mechanisms can sustain liquid production at near-normal levels in the fetal NKCC -/- mouse lung.

Macrolide antibiotics for cystic fibrosis.

BACKGROUND: Cystic Fibrosis is characterised by chest infection, the antibiotic treatment of which has significantly improved the outlook for people with this condition. The unusual nature of organisms that infect the chest of individuals with cystic fibrosis has restricted antibiotic choice. In particular the bacteria, Pseudomonas aeruginosa, is resistant to nearly all antibiotics that can be taken by mouth. There is laboratory evidence and evidence from other disease processes that macrolide antibiotics, whilst not directly active against Pseudomonas aeruginosa, may have indirect actions against this bacteria. OBJECTIVES: This review aimed to test the hypotheses that macrolide antibiotics; 1) Improve clinical status compared to placebo or another antibiotic 2) do not have unacceptable adverse effects If benefit was demonstrated, we aimed to assess the optimal type, dose and duration of macrolide therapy. SEARCH STRATEGY: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group specialist trials register which comprises references identified from comprehensive electronic database searches, handsearching relevant journals and handsearching abstract books of conference proceedings. In addition, Principal Investigators, known to work in the field and previous authors were contacted for unpublished or follow up data. Pharmaceutical companies, that manufacture macrolide antibiotics, were approached. SELECTION CRITERIA: Randomised controlled trials, published or unpublished, of macrolide compared to placebo, another class of antibiotic or another macrolide. Studies which compare regimes of the same macrolide at different doses will also be included. DATA COLLECTION AND ANALYSIS: No completed randomised controlled trials were identified. MAIN RESULTS: Three open studies excluded. Four ongoing randomised controlled trials were identified. No completed randomised controlled trials were identified. REVIEWER'S CONCLUSIONS: At present, there are no randomised controlled trials to evaluate the use of macrolide antibiotics for the treatment of chest infection in people with cystic fibrosis. Such trials, with clear outcome measures, are needed to properly evaluate this potentially useful treatment for cystic fibrosis.

Effects of adenosine, ATP, and UTP on chloride secretion by epithelia explanted from fetal rat lung.

Catecholamines trigger the switch from liquid secretion to absorption by perinatal lung, but regulation of Cl- and liquid secretion by pulmonary epithelia early in lung development (low [catecholamine]) is unknown. We looked for evidence for P1 and P2 receptors that mediate Cl- secretion in 14-d distal lungs and 14- and 18-d tracheas explanted from fetal rats (term = 22 d). We measured amiloride-insensitive transepithelial voltage changes induced by ATP, UTP, or adenosine. Explants were hyperpolarized by all three agonists and by terbutaline, a beta-adrenergic agonist and Cl- secretagogue. Whereas adenosine, ATP, or UTP injected into 14-d explant lumena, or adenosine added to the tracheal bath, induced hyperpolarization with EC50 of 2-15 microM EC50, values for all three agonists in the distal lung bath or ATP or UTP in the tracheal bath were five times greater. By 18 d, EC50 values for agonists in the bath were comparable to those for lumenal agonists (3-12 microM). In contrast, microinjection of terbutaline into all explant lumena (final concentration = 3 x 10(-5) M) induced minimal hyperpolarization, whereas the same concentration in the bath raised bioelectric potential difference maximally. We conclude that 1) beta-adrenergic receptors are present on the basolateral membranes of cells of the pulmonary epithelium early in lung development, and 2) adenosine, ATP, and UTP receptors are present in apical membranes throughout lung epithelial development, but basolateral receptors for these agonists in distal lung or ATP/UTP in trachea function later in gestation. The putative distribution of P1 and P2 receptors suggests a role for agonists released from pulmonary epithelial cells in the regulation of liquid secretion early in lung development.

Efficient adenovirus-mediated gene transfer to basal but not columnar cells of cartilaginous airway epithelia.

Adenoviral vectors (AdV) developed for treatment of the pulmonary manifestations of cystic fibrosis (CF) can deliver, with high efficiency, transgenes to respiratory epithelial cells grown in culture. This study investigated the efficiency of AdV-mediated gene transfer to murine and human respiratory epithelium in vivo and concluded that the epithelial cells facing the lumen of the respiratory cartilaginous airways (columnar cells) are poorly transduced with AdV. Mechanical injury to the epithelium, however, leads to efficient in vivo gene transfer by exposing a susceptible epithelial subtype (basal cells). Increased gene transfer efficiency in vivo after injury is not a nonspecific response because the proliferative status of the epithelium after injury was shown not to correlate temporally to the increased transduction susceptibility of the epithelium. Although basal cells were the cell type transduced at the time of vector delivery, with time, basal cell differentiation to columnar cells occurred with maintenance of transgene expression. Collectively, these results show that murine and human cartilaginous airways are poorly transduced by AdV. To correct the cartilaginous airway CF bioelectrical defect in vivo, efforts should be directed to increase the tropism of AdV to the columnar airway epithelial cells.

Cl- secretion by trachea of CFTR (+/-) and (-/-) fetal mouse.

The absence of pathologic changes in newborn cystic fibrosis (CF) lung suggests that the fetal CF lung is inflated with a normal volume of liquid and that Cl- is secreted through paths other than the cystic fibrosis transmembrane conductance regulator (CFTR)-associated Cl- channel. We studied liquid content of distal lung and transepithelial electrical potential difference (PD) of cultured cystic tracheal explants from 16 to 19 day gestation fetal mice of CFTR (+/-)(heterozygous) females that were mated with CFTR (-/-) "knockout" males. Distal lung water content was not affected by fetal genotype. Basal PDs were not different (CFTR (+/-), 8.6 mV, and CFTR (-/-), 9.1 mV), and PDs of both groups were inhibited by intraluminal injection of amiloride (10(-4) M) (-25%) and after addition of bumetanide (10(-4) M) to the bath (-40%). Terbutaline (3 x 10(-5) M) induced a similar increase in PD (about 65%) in both groups. Intraluminal injection of ionomycin (2 x 10(-5) and 5 x 10(-6) M) raised PD in both groups (CFTR (+/-) by 32 and 27% and CFTR (-/-) by 41 and 11%). All of the increase in PD induced by terbutaline and ionomycin was inhibited by bumetanide. The PD response to terbutaline was not attenuated by pretreatment with ionomycin or the Ca2+ chelator BAPTA (10(-4) M). Ionomycin or ATP, but not terbutaline, increased intracellular Ca2+ concentration of isolated cultured tracheal epithelial cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Bioelectric properties of cultured monolayers from epithelium of distal human fetal lung.

Throughout intrauterine life, Cl(-)-rich liquid is secreted by the pulmonary epithelium. To evaluate the role of the most distal epithelium in liquid secretion, we measured bioelectric properties of monolayers composed of epithelial cells from acinar structures of postmortem human fetal lung (mean gestation, 22.3 wk; range, 18-24 wk). These monolayers formed high-resistance (R) barriers (mean R = 363 Ohm/cm2) when cultured in hormone-supplemented, serum-free medium. The transepithelial electrical potential difference (4.0 mV, lumen negative), was similar to that of whole fetal sheep lung in vivo. Equivalent short-circuit current (Ieq) was inhibited by apical amiloride (-20%), 5-(N-ethyl-N-isopropyl)-amiloride (-33 to -49%), or diphenylamine-2-carboxylate (DPC; -26%), and by basolateral ouabain (-77%), whereas apical 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid (DIDS) had no effect. Bumetanide added to the basolateral bath did not affect resting Ieq, but inhibited Ieq (-19%) in monolayers pretreated with apical amiloride, basolateral terbutaline, and apical ATP, and also inhibited Ieq (-22%) of monolayers pretreated with basolateral amiloride and DIDS. Ieq was stimulated by terbutaline (90-128%), ATP (70-186%), and ionomycin (141%). Stimulation of Ieq by these agents is compatible with induction of Cl- secretion through two pathways: channels that are opened by a rise in adenosine 3',5'-cyclic monophosphate, and channels that are opened by a rise in intracellular Ca2+. Inhibition of Ieq by apical DPC implies that Cl- secretion may contribute to basal Ieq.

Effect of gas composition on liquid secretion by explants of distal lung of fetal rat in submersion culture.

Throughout gestation, fetal lung is filled with liquid secreted by the pulmonary epithelium. Factors responsible for secretion and for induction of liquid absorption by postnatal lung are poorly understood. We studied effects of "fetal" (3% O2-8% CO2) and "postnatal" (21% O2-5% CO2) gas tensions and of low hormone concentrations [media with 10% charcoal-stripped fetal bovine serum (stFBS) or unstripped FBS] on water content and morphology of distal lung explanted from 14-, 20-, and 22-day fetal (term, 22 days) and 2-day neonatal rats and incubated in submersion culture. Water-to-dry weight ratios of freshly excised fetal whole lung at 20 (6.2) or 22 days (7.0) were greater than that of 2-day postnatal lung (4.7). Culture conditions did not affect water-to-dry weight ratio of cyst-forming 14-day explants (10.8) or acystic 2-day postnatal explants (2.4). Fetal gases and stFBS supported cyst formation in [and high water/dry weight (9.2, 12.6) of] 20- and 22-day explants. Cysts also formed in 20-day explants exposed to postnatal gases and stFBS (water/dry weight = 6.5). Other conditions resulted in minimal cyst formation by 20- and 22-day explants and in water/dry weight similar to that of freshly excised and drained distal lung from 22-day fetuses (2.1). Cysts were lined with cuboidal and thin epithelial cells. No cells were ciliated. We conclude that 1) secretion dominates liquid flow across epithelia of fetal rat lung until birth, 2) alveolar epithelium contributes to this secretion, and 3) liquid secretion by fetal distal lung late in gestation is regulated by gas composition.

Effects of hormones on potential difference and liquid balance across explants from proximal and distal fetal rat lung.

1. Fetal rat tracheas and lung buds form liquid-filled cysts in submersion culture. The volume that accumulates in cysts is driven by active Cl- secretion. 2. We examined the effects, on these explants, of hormones that induce liquid absorption by fetal sheep lung in vivo. Explants were impaled with microelectrodes to measure potential difference (PD). Liquid was estimated from explant weight. 3. Water/dry weight ratio of lung buds and tracheas after 8 days in culture averaged 12 and 22. Exposure of triiodothyronine (T3) and hydrocortisone (HC) followed by a physiological dose of adrenaline on day 7 for 24 h or by a maximal dose of terbutaline on day 8 for 4 h induced a 35% decrease in water/dry weight ratio of distal buds but not tracheas. No hormone, or combination of two hormones, affected the ratio for tracheas or lung buds. 4. Basal PDs of tracheas (18.9 mV) and lung buds (3.7 mV) were increased about 50% by terbutaline. The terbutaline response was inhibited by bumetanide, but not by amiloride injected into the cysts. 5. T3 and HC pretreatment reduced basal PD by one-third. Subsequent exposure to terbutaline raised the PD of hormone-pretreated lung buds by more than 150%, a response that was blocked by amiloride, but was antagonized minimally by bumetanide. Responses of hormone-pretreated tracheas were not different from those of untreated tracheas. 6. We conclude that: (a) absorption of liquid from lung buds is driven by an amiloride-sensitive process (active Na+ transport?) and (b) only distal lung contributes to the adrenaline-sensitive reabsorptive process required for perinatal adaptation to air breathing.

The effect of thyroidectomy in the fetal sheep on lung liquid reabsorption induced by adrenaline or cyclic AMP.

1. In fetal sheep at 113-120 days' gestation, thyroidectomy was performed and tracheal, arterial and venous catheters inserted. Following a recovery period experiments were performed from 120-145 days to measure changes in lung liquid secretion or its absorption in response to I.V. adrenaline infusion or to introduction of dibuteryl cyclic AMP into lung liquid. The results were compared with those previously obtained in non-thyroidectomized fetuses. 2. Plasma levels of thyroid hormones in non-thyroidectomized fetuses confirmed the pattern found by previous workers. In thyroidectomized fetuses the levels of thyroxine (T4), tri-iodothyronine (T3) and reverse T3 (rT3) were very low except in one fetus which showed biochemical evidence of thyroid regeneration towards the end of gestation. 3. In thyroidectomized fetuses the normal response to adrenaline infusion (diminution of reversal of lung liquid secretion) was profoundly suppressed and very little gestational maturation in this response took place, except in the one fetus with evidence of thyroid regeneration in which a normal reabsorptive response developed in late gestation. 4. In thyroidectomized fetuses, the normal response to dibuteryl cyclic AMP was greatly reduced and its increase with gestation which normally parallels that seen during adrenaline infusion did not take place.