Flying the nest: a challenge for young adults with cystic fibrosis and their parents.

OBJECTIVES: As young patients with cystic fibrosis (CF) grow up, they are expected to take increasing responsibility for the treatment and care of their disease. The aim of this study was to explore the disease-related challenges faced by young adults with CF and their parents, when they leave home. MATERIALS AND METHODS: A questionnaire survey of Danish patients with CF aged 18-25 years and their parents was conducted. The questionnaires were based on focus-group interviews with young adults with CF and their parents, and addressed challenges faced in the transition phase between childhood and adulthood, including different areas of disease management in everyday life. RESULTS: Among all of the patients invited, 62% (n=58/94) of young adults and 53% (n=99/188) of their parents participated in the study. In total, 40% of the 18- to 25-year-olds were living with their parents, and the parents continued to play an active role in the daily care of their offspring's disease. Among the young adults who had left home, both the patients and their parents reported many difficulties regarding disease management; the young adults reported difficulties in contacting social services and in affording and preparing sufficient CF-focused meals, and their parents reported difficulties in answering questions concerning social rights and CF in general, and in knowing how to give their offspring the best help, how much to interfere, and how to relinquish control of managing their offspring's disease. CONCLUSION: Young adults with CF who have left home have difficulties in handling the disease and their parents have difficulties in knowing how to give them the best help. There is an urgent need for holistic CF transitional care, including ensuring that young adults master the essential skills for self-management as they leave their parents.

Lack of evidence of increased risk of bacterial transmission during cystic fibrosis educational programmes.

BACKGROUND: Educational and rehabilitation programmes increase the quality-of-life of patients with cystic fibrosis, but patients are discouraged to participate because of the risk of cross-infections. METHODS: Isolates of Pseudomonas aeruginosa, Staphylococcus aureus and Haemophilus influenzae cultured one year before to one year after attendance were investigated by pulsed field gel electrophoresis, multilocus sequence typing and/or spa-typing. RESULTS: We typed 984 bacterial isolates cultured from 46 patients aged 5-18 years attending educational programmes at Aarhus University Hospital during 2009-2011. There were no cross-infections with P. aeruginosa. Six cases of S. aureus or H. influenzae strain replacement with a new strain-type shared with a fellow attendee were found. However, the probability of acquiring a shared strain of S. aureus or H. influenzae was not increased for patients attending educational programmes. CONCLUSIONS: Transmission of P. aeruginosa, S. aureus and H. influenzae related to attendance to the investigated educational programmes could not be documented.

Molecular and stimulus-response profiles illustrate heterogeneity between peripheral and cord blood-derived human mast cells.

Different protocols exist for in vitro development of HuMCs from hematopoietic stem cells, which results in distinct mast cells regarding molecular markers and activation patterns. Here, we introduce a SR profile using immunological, neurogenic, and pharmacological stimuli to characterize cellular functionality. Mast cells were obtained from three culture protocols using two types of PBdMCs (CD34⁺ PBdMC or CD133⁺ PBdMC) and one type of CBdMC (CD133⁺ CBdMC). We analyzed resting cells for specific mast cell markers at protein and mRNA levels, thereby creating a molecular profile. To characterize the SR profile, we stimulated cells with anti-IgE, C3a, C5a, Substance P, or Compound 48/80 and measured the release of histamine and cytokines (IL-10, IL-13, GM-CSF, TNF-α). Molecular profiling revealed that CD133⁺ CBdMC expressed less chymase, FcεRIα, and CD203c but more CD117 compared with CD34⁺ and CD133⁺ PBdMC. The SR profile for histamine release illustrated a functional heterogeneity between PBdMC and CBdMC. PBdMC released >10% histamine upon stimulation with anti-IgE, C3a, Substance P, and Compound 48/80, whereas CBdMC only reacted to C3a. Cytokine secretion was only detected after anti-IgE stimulation. Here, the SR profile identified the CD133⁺ PBdMC as the most active cells regarding secretion of IL-10, IL-13, GM-CSF, and TNF-α. Cells from all three culture protocols, however, produced IL-10 spontaneously at comparable levels. We recommend validating mast cell cultures by means of molecular and SR profiles to characterize the mast cells and enhance consensus among studies.

Mast cell FcϵRI density and function dissociate from dependence on soluble IgE concentration at very low and very high IgE concentrations.

OBJECTIVE: The contribution of affinity, clonality, and concentration of individual IgE species to effector cell response has recently been characterized in a model with recombinant human IgE on passively sensitized basophils. This study extends the dependence of effector cell degranulation on IgE concentration to mast cells cultured with IgE for 2 weeks. METHODS: Human mast cells cultured for 7 weeks from peripheral blood stem cells were matured for 2 weeks with interleukin-4 (IL-4) and recombinant human IgE consisting of two clones specific for Dermatophagoides pteronyssinus 2 (Derp2) (7% + 7%) and unspecific IgE at 0.8, 8, 80, and 800 kU/L. The density of the IgE receptor, FcϵRI, and mast cell function were measured after challenging with recombinant Derp2 at 14 concentrations from 10 fg/mL to 100 pg/mL. CD63 expression, histamine release, and Prostaglandin D2 (PGD(2)) synthesis were measured, and maximal expression and mast cell sensitivity were calculated. RESULTS: At 800 kU/L IgE, FcϵRI expression varied more than at 80, 8, and 0.8 kU/L IgE. There was a trend toward increased maximal expression of CD63, histamine release, and PGD(2) secretion with increasing IgE concentration. At 0.1 kU/L specific IgE, the LC50 increased up to fivefold, least so for PGD(2). CONCLUSIONS: Human mast cells cultured with rhIgE of known composition are a sensitive model for studying factors governing effector cell degranulation that is close to the in vivo situation. This model can be used to study effects of IgE concentration, clonality, and affinity and may help predict the optimal immunologic treatment for a given patient.

Cultured human mast cells are heterogeneous for expression of the high-affinity IgE receptor FcεRI.

OBJECTIVE: We determined the density of FcεRI on mast cells cultured from cord (CBMC) and peripheral blood (PBMC) and studied the kinetics of the response through FcεRI. METHODS: Mast cells were cultured from CD133+ progenitors from peripheral or cord blood. FcεRI was stabilized by culture with 2 µg/ml IgE. Cells were activated by addition of anti-FcεRI antibody (1 ng/ml-10 µg/ml). Maximal activation, sensitivity, and cooperativity were determined. RESULTS: All cultures were homogeneous for tryptase and metachromasy. All cells expressing FcεRI could be activated by cross-linking FcεRI to upregulate CD63. PBMC bind 203,000 molecules of IgE/cell. Stabilization of FcεRI with IgE doubled the number of CD63+ cells (p = 0.0001) and increased the sensitivity (from 0.083 to 0.013 µg/ml anti-FcεRI) and the slope factor (from 10.8 to 68) of PBMC but not of CBMC. Anti-IgE reversed these effects (p = 0.0002) but did not reduce activation levels below that of cell lines not stabilized with IgE. CONCLUSION: Baseline expression of FcεRI is independent of anti-IgE. The fraction of PBMC that binds high levels of IgE can be activated through FcεRI.

Barriers to adherence in adolescents and young adults with cystic fibrosis: a questionnaire study in young patients and their parents.

BACKGROUND: Treatment adherence is crucial in patients with cystic fibrosis, but poor adherence is a problem, especially during adolescence. Identification of barriers to treatment adherence and a better understanding of how context shapes barriers is of great importance in the disease. Adolescent reports of barriers to adherence have been studied, but studies of their parents' experience of such barriers have not yet been carried out. The aim of the present study was to explore barriers to treatment adherence identified by young patients with cystic fibrosis and by their parents. METHODS: A questionnaire survey of a cohort of young Danish patients with cystic fibrosis aged 14-25 years and their parents was undertaken. RESULTS: Barriers to treatment adherence were reported by 60% of the patients and by 62% of their parents. Patients and parents agreed that the three most common barriers encountered were lack of time, forgetfulness, and unwillingness to take medication in public. We found a significant positive correlation between reported number of barriers and perceived treatment burden. We also found a statistically significant relationship between the reported number of barriers and treatment adherence. A significant association was found between the number of barriers and the reactions of adolescents/young adults and those of their mothers and fathers, and between the number of barriers and the way the family communicated about cystic fibrosis. CONCLUSION: The present study showed that the majority of adolescents with cystic fibrosis and their parents experienced barriers to treatment adherence. Agreement between adolescents and their parents regarding the level and types of barriers indicates an opportunity for close cooperation between adolescents, their parents, and health care professionals in overcoming adolescent adherence problems.

Parenting adolescents with cystic fibrosis: the adolescents' and young adults' perspectives.

BACKGROUND: When suffering from cystic fibrosis (CF), a number of problems may arise during adolescence; for example, poor adherence. The problems may be attributed to the adolescent being insufficiently prepared for adult life. Research on different ways of parenting adolescents with CF and the influence of different parenting styles on the adolescents' adherence to treatment is still limited. AIM: The aim of this study was to identify the types of parental support that adolescents and young adults with CF want and find helpful in terms of preparing them for adult life. METHODS: Sixteen Danish adolescents with CF, aged 14-25, participated in the study. Two focus group interviews were carried out, one for 14-18-year-olds and one for 19-25-year-olds. Individual interviews were conducted, with three subjects. Using interpretive description strategy, a secondary analysis of the interview data was conducted. RESULTS: The adolescents and young adults wanted their parents educated about the adolescent experience. They wanted their parents to learn a pedagogical parenting style, to learn to trust them, and to learn to gradually transfer responsibility for their medical treatment. Additionally, the adolescents noted that meeting other parents may be beneficial for the parents. CONCLUSION: The findings of this study suggest that adolescents and young adults with CF want their parents to be educated about how to handle adolescents with CF and thereby sufficiently prepare them for adult life.

Serum-surfactant SP-D correlates inversely to lung function in cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) affects the lungs causing infections and inflammation. Surfactant protein D (SP-D) is an innate defense lectin primarily secreted in the lungs. We investigated the influence of the SP-D Met11Thr polymorphism on CF lung function; and serum SP-D as a marker for CF lung disease. METHODS: For 107 CF patients (73 children, and 34 adults) serum SP-D and SP-D Met11Thr genotype were available. Leukocyte count was obtained for a subset of patients. Lung function was measured as forced expiratory volume in one second (FEV-1). RESULTS: Serum SP-D was increased in CF patients compared to healthy controls, positively correlated to leukocyte count, and negatively correlated to FEV-1. We found no correlation between SP-D Met11Thr genotype and FEV-1, and we found corresponding genotype frequencies in CF patients and in healthy controls. CONCLUSION: Serum SP-D in CF patients was increased in parallel with leukocyte count and with reduced FEV-1 and may constitute an alternative biomarker for lung disease, in the clinical setting and in research.

Validation of the Danish version of the revised cystic fibrosis quality of life questionnaire in adolescents and adults (CFQ-R14+).

BACKGROUND: Quality of life is an important parameter in the evaluation of quality and outcome of health care and treatment, especially in patients with chronic disorders. The aim of this study was to assess the validity and reliability of the Danish version of the revised disease-specific health-related quality of life questionnaire for adolescents and adults with cystic fibrosis (CFQ-R14+). METHODS: A total of 196 cystic fibrosis (CF) patients completed the CFQ-R14+ (response rate 71%). Forced expiratory volume in 1 s in percentage of predicted (FEV(1)%) and body mass index (BMI) were included as measures of health status. RESULTS: Internal consistency coefficients ranged from 0.54 to 0.95. Eight out of the twelve scales had alpha coefficients above 0.7. Test-retest correlations ranged from 0.42 to 0.88 and they were significant in eight scales. All the CFQ-R+14 scales except the digestive symptoms scale discriminated significantly (p<0.05) between patients with mild, moderate, and severe disease. Nine out of the twelve scales discriminated significantly (p<0.05) between nourished (BMI> or =19) and malnourished (BMI<19) patients. Significant differences between participants and non-responders were found for age, sex and FEV(1) (higher age, more males and lower FEV(1) among non-responders). All of the scales met standards for floor effects (<15% of the responders with the lowest score) but five of the scales failed to meet standards for ceiling effects (>15% of the responders with the highest score). CONCLUSION: The Danish CFQ-R14+ is a reliable and valid instrument for measuring the health-related quality of life in Danish adolescents and adults with CF, though with the exception from a few of its subscales.

Seven week culture of functional human mast cells from buffy coat preparations.

Functional, mature human mast cells have been generated by in vitro differentiation of CD133(+)/CD34(+) progenitor cells isolated from e.g. cord blood, peripheral blood, bone marrow or fetal liver. However, the protocols published so far require long term cultivation, i.e. up to 15 weeks for mast cell differentiation, which makes such approaches not only laborious but also costly. Here, we have developed a protocol for generating functional human mast cells from peripheral blood already within 7 weeks. Human CD133(+) progenitors were isolated from buffy coat preparations of peripheral blood and cultured in the presence of stem cell factor (SCF) and IL-6 for 7 weeks. IL-3 was added to the culture medium during the first 3 weeks, and fetal calf serum (FCS) added during the last week. In vitro differentiated CD133(+) cells exhibited multiple characteristics of mature mast cells. Thus, cells contained tryptase and expressed functional levels of FcepsilonRI. Anti-IgE stimulation induced significant release of histamine and PGD(2) and also of chemokines including MCP-1, IL-8, MIP-1alpha, and MIP-1beta. The fact that our in vitro differentiated mast cells are derived from a generally available source of progenitor cells makes this novel protocol widely applicable to any patient group, irrespective of age. Moreover, this progenitor source is more readily available than e.g. bone marrow or cord blood-derived progenitors. Consequently, our protocol has great potential in studies on mast cell biology and mast cell pathology, and e.g. on evaluation of drug effects.

Comparison of short term in vitro cultured human mast cells from different progenitors - Peripheral blood-derived progenitors generate highly mature and functional mast cells.

During the last two decades different scientific groups have investigated the phenotype and function of in vitro generated human mast cells (MC). The cells have been shown to display variable surface markers and functional characteristics. The phenotypic differences may reflect different culture conditions, protocols or the use of different progenitors. To investigate the significance of different progenitors, we have compared MC generated from CD133(+) progenitor cells from cord blood (CBMC) or peripheral blood (PBMC). The progenitors were cultured for 7 weeks in the presence of IL-6 and SCF, with addition of IL-3 the first 3 weeks, and FCS during week 7. The phenotype of the established MC was characterized by surface marker expression levels, metachromasia, histamine and tryptase contents and their function was evaluated by receptor-mediated release of histamine and PGD(2). The generated metachromatic (<99%) MC were 75% tryptase(+), regardless of the source of progenitor cell. Expression of c-kit/CD117, CD203c, and FcepsilonRI was comparable. The density of c-kit/CD117 receptors on CBMC was higher that of PBMC (p<0.001). The density of CD203c and FcepsilonRI was higher on PBMC (p<0.001). PBMC contained more histamine (p<0.001), expressed more FcepsilonRI (p<0.001) and released more histamine (p<0.001) and PGD(2) (p<0.001) upon ligation of FcepsilonRI, than CBMC. Culture with IL-4 increased expression of tryptase, FcepsilonRI, CD117 and CD203c, secretion of histamine and PGD(2) of PBMC, and histamine secretion of CBMC. Cord and peripheral blood may give rise to different types of MC. The question addressed should determine the progenitor cell and protocol to be used.

Viral and atypical bacterial infections in the outpatient pediatric cystic fibrosis clinic.

BACKGROUND: Respiratory viral and atypical bacterial infections are associated with pulmonary exacerbations and hospitalisations in cystic fibrosis patients. We wanted to study the impact of such infections on children attending the outpatient clinic. METHODS: Seventy-five children were followed for 12 months at regular clinic visits. Routine sputum/laryngeal aspirations were tested with PCR for 7 respiratory viruses. Antibodies against C. pneumoniae, M. pneumoniae and B. pertussis were measured every 3-4 months. FEV-1, FEF(25-75) and specific airway resistance, "viral" symptoms and bacterial culture were recorded. RESULTS: Ninety-seven viral and 21 atypical bacterial infections were found. FEV-1 was significantly reduced during viral infection (-12.5%, p=0.048), with the exception of rhinovirus infection. A small change in FEV-1 (-3%) was seen during atypical bacterial infection (p=0.039). Viral and atypical bacterial infections caused no change in type and frequency of bacterial culture. Positive predictive value of "viral symptoms" was low (0.64%). Eight patients received "unnecessary" antibiotics because of viral symptoms. CONCLUSIONS: Some viral infections and atypical bacterial infections affect FEV-1 acutely. Viral infections did not precipitate bacterial infection or change of colonisation. Clinical symptoms failed to diagnose viral infection accurately. Routine surveillance for virus or atypical bacteria seems not to be justified in this patient category.