Vito Terlizzi

Hyaluronic acid improves “pleasantness” and tolerability of nebulized hypertonic saline in a cohort of patients with cystic fibrosis

IntroductionInhaled hypertonic saline improves lung function and decreases pulmonary exacerbations in people with cystic fibrosis. However, side effects such as cough, narrowing of airways and saltiness cause intolerance of the therapy in 8% of patients. The aim of our study was to compare the effect of an inhaled solution of hyaluronic acid and hypertonic saline with hypertonic solution alone on safety and tolerability.MethodsA total of 20 patients with cystic fibrosis aged 6 years and over received a single treatment regimen of 7% hypertonic saline solution or hypertonic solution with 0.1% hyaluronate for 2 days nonconsecutively after a washout period in an open crossover study. Cough, throat irritation, and salty taste were evaluated by a modified ordinal score for assessing tolerability; “pleasantness” was evaluated by a five-level, Likert-type scale. Forced expiratory volume in 1 second was registered before and after the end of the saline inhalations.ResultsAll 20 patients (nine males, 11 females, mean age 13 years, range 8.9–17.7) completed the study. The inhaled solution of 0.1% hyaluronic acid and hypertonic saline significantly improved tolerability and pleasantness compared to hypertonic saline alone. No major adverse effects were observed. No difference was documented in pulmonary function tests between the two treatments.ConclusionHyaluronic acid combined with hypertonic saline solution may contribute to improved adherence to hypertonic saline therapy. Further clinical trials are needed to confirm our findings. Considering the extraordinary versatility of hyaluronic acid in biological reactions, perspective studies could define its applicability to halting progression of lung disease in cystic fibrosis.

Clinical expression of patients with the D1152H CFTR mutation

BACKGROUND Discordant results were reported on the clinical expression of subjects bearing the D1152H CFTR mutation, and also for the small number of cases reported so far. METHODS A retrospective review of clinical, genetic and biochemical data was performed from individuals homozygous or compound heterozygous for the D1152H mutation followed in 12 Italian cystic fibrosis (CF) centers. RESULTS 89 subjects carrying at least D1152H on one allele were identified. 7 homozygous patients had very mild clinical expression. Over half of the 74 subjects compound heterozygous for D1152H and a I-II-III class mutation had borderline or pathological sweat test and respiratory or gastrointestinal symptoms; one third had pulmonary bacteria colonization and 10/74 cases had complications (i.e. diabetes, allergic bronchopulmonary aspergillosis, and hemoptysis). However, their clinical expression was less severe as compared to a group of CF patients homozygous for the F508del mutation. Finally, 8 subjects compound heterozygous for D1152H and a IV-V class mutation showed very mild disease. CONCLUSIONS The natural history of subjects bearing the D1152H mutation is widely heterogeneous and is influenced by the mutation in trans.

Primary herpes virus infection and ischemic stroke in childhood: a new association?

We describe, to our knowledge, the first case of arterial ischemic stroke after primary herpes simplex virus type 1 (HSV1) infection in a previously healthy child, without signs of encephalitis. A 10-year-old previously healthy girl was admitted to our hospital with acute left-sided hemiparesis which involved the lower half of her face. Submandibular lymphadenitis and oral vesicular lesions were present. MRI confirmed the suspicion of an acute ischemic stroke. Immunoglobulin M antibodies to HSV1 were detected. Cerebrospinal fluid polymerase chain reaction for herpes virus was negative. She was treated with aspirin (3mg/kg) and intravenous acyclovir (10mg/kg every 8 hours) for 21 days. Immunoglobulin G antibodies to HSV1 appeared 16 days after admission. Twelve months after her hospitalization the patients examination was normal. Stroke should be considered a possible complication of HSV1 primary infection. Guidelines for the management of acute stroke in children are needed.

Prediction of acute pancreatitis risk based on PIP score in children with cystic fibrosis

BACKGROUND Currently no tools to predict risk of acute (AP) and recurrent pancreatitis (ARP) in children with cystic fibrosis (CF) are available. We assessed the prevalence of AP/ARP and tested the potential role of Pancreatic Insufficiency Prevalence (PIP) score in a cohort of children with CF. METHODS We identified two groups of children, on the basis of presence/absence of AP/ARP, who were compared for age at diagnosis, clinical features, genotypes and sweat chloride level. PIP score was calculated for each patient. RESULTS 10/167 (5.9%) experienced at least one episode of AP during follow up; 10/10 were pancreatic sufficient (PS). Patients with AP/ARP showed a PIP score ≤0.25 more frequently (6/10) than patients without AP/ARP. The odds ratio (95% CI) of developing pancreatitis was 4.54 (1.22-16.92) for patients with PIP <0.25 when compared with those who have a PIP score >0.25 (p 0.0151). PIP score was correlated with sweat chloride test (p < 0.01). CONCLUSION PIP score, PS status and normal/borderline sweat chloride levels could be applied to predict pancreatitis development in children with CF. ARP could lead to pancreatic insufficiency.

Genotype–phenotype correlation and functional studies in patients with cystic fibrosis bearing CFTR complex alleles

Background The effect of complex alleles in cystic fibrosis (CF) is poorly defined for the lack of functional studies. Objectives To describe the genotype–phenotype correlation and the results of either in vitro and ex vivo studies performed on nasal epithelial cells (NEC) in a cohort of patients with CF carrying cystic fibrosis transmembrane conductance regulator (CFTR) complex alleles. Methods We studied 70 homozygous, compound heterozygous or heterozygous for CFTR mutations: p.[Arg74Trp;Val201Met;Asp1270Asn], n=8; p.[Ile148Thr;Ile1023_Val1024del], n=5; p.[Arg117Leu;Leu997Phe], n=6; c.[1210-34TG[12];1210-12T[5];2930C>T], n=3; p.[Arg74Trp;Asp1270Asn], n=4; p.Asp1270Asn, n=2; p.Ile148Thr, n=6; p.Leu997Phe, n=36. In 39 patients, we analysed the CFTR gating activity on NEC in comparison with patients with CF (n=8) and carriers (n=4). Finally, we analysed in vitro the p.[Arg74Trp;Val201Met;Asp1270Asn] complex allele. Results The p.[Ile148Thr;Ile1023_Val1024del] caused severe CF in five compound heterozygous with a class I–II mutation. Their CFTR activity on NEC was comparable with patients with two class I–II mutations (mean 7.3% vs 6.9%). The p.[Arg74Trp;Asp1270Asn] and the p.Asp1270Asn have scarce functional effects, while p.[Arg74Trp;Val201Met;Asp1270Asn] caused mild CF in four of five subjects carrying a class I–II mutation in trans, or CFTR-related disorders (CFTR-RD) in three having in trans a class IV–V mutation. The p.[Arg74Trp;Val201Met;Asp1270Asn] causes significantly (p<0.001) higher CFTR activity compared with compound heterozygous for class I–II mutations. Furthermore, five of six compounds heterozygous with the p.[Arg117Leu;Leu997Phe] had mild CF, whereas the p.Leu997Phe, in trans with a class I–II CFTR mutation, caused CFTR-RD or a healthy status (CFTR activity: 21.3–36.9%). Finally, compounds heterozygous for the c.[1210-34TG[12];1210-12T[5];2930C>T] and a class I–II mutation had mild CF or CFTR-RD (gating activity: 18.5–19.0%). Conclusions The effect of complex alleles partially depends on the mutation in trans. Although larger studies are necessary, the CFTR activity on NEC is a rapid contributory tool to classify patients with CFTR dysfunction.

Simple diagnosis of benign acute childhood myositis: Lessons from a case report

Acute muscle pain and walking difficulty are symptoms compatible with both benign and severe degenerative diseases. As a consequence, in some cases invasive tests and hospitalizations are improperly scheduled. We report the case of a 7-year-old child suffering from acute calf pain and abnormal gait following flu-like symptoms. A review of the literature will be helpful to better define differential diagnosis in cases of muscle pain in children. Daily physical examination and urine dipstick are sufficient to confirm the diagnosis of benign acute childhood myositis (BACM) during the acute phase, to promptly detect severe complications and to rule out degenerative diseases. Children with BACM do not require hospitalization, medical interventions or long-term follow-up.

Hepatic steatosis is uncommon in children with chronic hepatitis B.

BACKGROUND Differently from chronic hepatitis C, factors associated with hepatic steatosis in children with chronic hepatitis B are not clearly elucidated. OBJECTIVE Aim of this study was to investigate prevalence of steatosis at liver biopsy in HBV-infected children. STUDY DESIGN A retrospective study including 56 children with chronic hepatitis B undergoing liver biopsy at median age of 8.1 years. In all patients demographic, anthropometric, clinical and laboratory data were evaluated at the time of liver biopsy. RESULTS Steatosis was present in 2 (4%) children. BMI was significantly higher in 2 patients with steatosis compared with those without steatosis. Demographic, biochemical and virological parameters did not differ between children with and those without steatosis. CONCLUSIONS Liver steatosis in HBV-infected children seems to be related to obesity and metabolic factors rather than to viral factors. Detection of steatosis in non-obese children with HBV infection requires a careful investigation to rule out other causes of fatty liver.

Children with chronic hepatitis C: what future?

cise capacity does not necessarily require “strict monitoring ensured by a cardiologist”. In our study, we performed maximal symptomlimited treadmill testing in 37 individuals with NAFLD without adverse events, despite the fact that most patients manifested several comorbidities. Obviously, appropriate management of comorbidities will clearly reduce the risk of an adverse event during physical activity participation of submaximal exertion. Requiring cardiologist supervision for physical activity participation adds another potentially significant barrier (and expense) for these patients to adopt and maintain a regular exercise program. We certainly agree that our lack of appropriate control groups (nonobese, albeit with abdominal obesity, one with both insulin resistance [IR] and NAFLD and the other with only IR) is a limitation of this study. However, the intent of this initial study was to determine whether objective measures of health-related fitness and physical activity differ with severity of NAFLD. Furthermore, in practice, it would be quite difficult to include such control groups of meaningful size for the following reasons: (1) nonobese patients with IR and NAFLD are relatively uncommon and (2) patients with IR without NAFLD frequently lack histological confirmation.4,5 Indeed, reduced lean mass, small cross-sectional muscle fiber area, and increased triglyceride deposition in skeletal muscle in conjunction with dysfunctional/reduced lipolysis can result in reduced cardiorespiratory fitness. However, it is unknown whether these adaptations take place as a result of reduced physical activity, NAFLD, or both. We agree entirely that for exercise to be successfully implemented as a therapeutic strategy there is a strong need for individualized exercise prescription. As such, we have recently submitted a manuscript for publication that reviews the evidence for exercise training as a therapy for NAFLD and also presents the principles for prescribing exercise as a therapeutic intervention. Future studies will endeavor to better determine the relative contributions of IR, adiposity, and NAFLD to reduced fitness. JOANNE B. KRASNOFF, PH.D.1 NATHAN M. BASS, M.D., PH.D.2 PATRICIA L. PAINTER, PH.D.3 RAPHAEL B. MERRIMAN, M.B.4 1University of California San Francisco, Clinical and Translational Science Institute Clinical Research Center, Exercise Physiology & Body Composition Laboratory, San Francisco, CA 2University of California San Francisco, Division of Gastroenterology, San Francisco, CA 3University of Minnesota, Division of Renal Diseases and Hypertension, Minneapolis, MN 4California Pacific Medical Center and Research Institute, Division of Gastroenterology, San Francisco, CA

10 The role of complex alleles in patients with cystic fibrosis and L997F

Objective: The c.3909C>G (N1303K) is the most frequent mutation after the c.1521_1523delCTT (F508del) in Lebanon. A CFTR gene screening was performed on 10 Lebanese and 5 French CF patients carrying c.3909C>G. Parental studies revealed that all individuals have an association of c.3909C>G (exon 24) with c.869+11C>T (intron 7) in cis, inducing a new complex allele (CA). Since both mutations are located in two distant regions, we studied their combined impact by two plasmid constructions. Method: Firstly, we studied the impact of c.3909C>G on alternative splicing (AS), localization and maturation of the CFTR protein. Secondly, to study the impact of c.869+11C>T on AS, an ex-vivo study will be conducted using a plasmid containing the exon 7 and its flanking introns. After transfection of different type of eukaryotic cells, RNA extraction and RT-PCR, cDNA will be sequenced to verify the possible AS. Results: We showed that c.3909C>G affects the localization and the process. The in-silico study is in favor for a possible role of c.869+11C>T in AS. In fact, the used algorithm human splicing Finder showed that c.869+11C>T might affect the AS since it is located near the donor site. Conclusion: The class II mutation, c.3909C>G, induces mild phenotype with few CFTR on membrane. We suggest that the CA c.[869+11C>T;3909C>G], will act like a class I mutation, explaining the severe phenotype in some c.3909C>G patients. So, the classification of a mutation is not sufficient in a clinical approach, as the possible presence of a CA may alter its the specific effect. Therefore, an individualized approach is required to perform proper diagnostic and treatment when available.

225 PIP score could predict the risk of pancreatitis in patients with cystic fibrosis (CF)

Objective: To assess the level of fecal elastase-1 (FE-1) in relation to CFTR gene mutations in patients with cystic fibrosis (CF). Materials and Methods: This study included 49 patients (23 boys) with CF, mean age 8.43±0.99 years. CF was established on the basis of a positive sweat test (Macroduct, Wescor USA) and the results of molecular genetic analysis. Genetic diagnosis was realized for 36 CFTR mutations in genetic laboratories from Germany and France. To detect pancreatic insufficiency (PI) was defined FE-1 (ScheBo Biotech, Germany). The values of FE-1 in the range 0–100mg/g, are characteristic for severe exocrine PI, 100–200mg/g for moderate exocrine PI, and >200mg/g for pancreatic sufficiency. Results: F508del mutation was revealed in 73.33% cases (40.0% − homozygotes), known genotype with other mutations was found in 18.26% cases. Low values of FE-1 (7.89±3.70mg/g) confirmed exocrine PI in 81.64% patients with CF. PI with FE-1 of 2.90±0.78mg/g was confirmed in 100% children with homozygous state of F508del mutation. F508del mutation in heterozygous state caused decreased levels of FE-1 (33.69±19.34mg/g). Only 5.88% patients with CF F508del heterozygous were pancreatic sufficient and other 11.7% cases were moderate PI. Non-F508del CFTR mutations determined FE-1 levels of 218.64±64.87mg/g, with PI in 57.89% patients. Conclusion: The F508del mutations in homozygous state were associated with severe pancreatic exocrine insufficiency in all patients. Heterozygous state of mutation F508del requires association with another mutation and in most cases led to pancreatic enzyme deficiency. Non-F508del CFTR mutations are not obligatory associated with PI.