No hearing loss after repeated courses of tobramycin in cystic fibrosis patients.

Acta Otolaryngol. 2009 May 28:1-6. [Epub ahead of print]

Related Articles

No hearing loss after repeated courses of tobramycin in cystic fibrosis patients.

Scheenstra RJ, Heijerman HG, Zuur CL, Touw DJ, Rijntjes E.

Department of Otorhinolaryngology, Head and Neck Surgery, The Netherlands Cancer Institute, Amsterdam.

Conclusion: Our results indicate that repeated treatment courses with tobramycin 10 mg/kg (twice daily for 3 weeks) may be safely applied in cystic fibrosis (CF) patients with respect to ototoxicity. The risk of hearing loss in this patient group is less than expected, which could be explained by either unfavourable baseline audiometry or the use of unidentified protective medication, or both. However, due to large inter-individual variations, audiometry screening remains important with respect to the detection of individual outliers. Objectives: Tobramycin is frequently prescribed for CF patients. In this study, hearing loss due to cumulative tobramycin exposure in adult CF patients was investigated. Patients and methods: We retrospectively investigated 19 patients with both baseline and follow-up audiometry before and after repeated courses of intravenous tobramycin (10 mg/kg/day in twice daily administrations for 3 weeks). Pure tone audiometry was performed at 0.250-16 kHz. Results: After repeated courses of tobramycin (median 3, range 1-8), the mean increase per frequency was 2.1 dB (median 0.5 dB, SD 12.6) with large (inter-individual) variations (range -23.5 to 34.5 dB). The pure tone averages (PTA) at 1-2-4 kHz and 8-10-12 kHz increased 1.4 dBHL and 2.3 dBHL, respectively, but were neither statistically significant, nor correlated with the cumulative tobramycin exposure.

PMID: 19479457 [PubMed - as supplied by publisher]

http://www.ncbi.nlm.nih.gov/pubmed/19479457?dopt=Abstract

clinicaltrials.gov links for 3 vertex studies

So for my own record and for those who are interested, here are the links for the Vertex 770 Phase III trials



http://www.clinicaltrials.gov/ct2/show/NCT00909727?term=vertex&rank=21 ages 6-11


http://www.clinicaltrials.gov/ct2/show/NCT00909532?term=vertex&rank=22 ages 12+



And for Vertex 809 Phase II study:


http://www.clinicaltrials.gov/ct2/show/NCT00865904?term=vertex&rank=3

Senator Shelby and Acting NIH Director Raynard Kington Praise CF Foundation at Hill Hearing and Call for Ongoing Funding

Senator Shelby and Acting NIH Director Raynard Kington Praise CF Foundation at Hill Hearing and Call for Ongoing Funding

May 28, 2009

Senator Richard Shelby (R-AL), a champion of CF research, spoke at length about advances in CF research during a Senate Appropriations Committee hearing last week. He addressed the critical need for increased research funding for rare diseases like CF.

During the hearing, Acting NIH Director Raynard Kington, M.D., Ph.D., and other NIH institute directors, praised the work of the CF Foundation and the CF community. “The CF community is in many ways held up as a good example of how a community affected by a disease can work collaboratively with the research community to facilitate translation,” said Kington.

Also during the hearing, Shelby, Kington and Elizabeth G. Nabel, M.D., director of the National Heart, Lung, and Blood Institute, suggested that NIH mirror the Foundation’s successful clinical trials network (also known as the Therapeutics Development Network), and its research model to gain better results for rare disease research.

“If we take a minute and reflect on the progress that’s been made in cystic fibrosis, it’s been remarkable over the past decade,” Nabel said. Nabel also cited recent media coverage the CF Foundation received in the The New Yorker.

http://www.cff.org/aboutCFFoundation/NewsEvents/index.cfm?ID=11535&TYPE=1670

Soon Recruiting: Cipro Inhaler for Cystic Fibrosis Children Ages 6-12

Cipro Inhaler for Cystic Fibrosis Children Ages 6-12


http://www.clinicaltrials.gov/ct2/show/NCT00910351?term=cystic+fibrosis&recr=Open

Vertex Pharmaceuticals Inc. has launched Phase 3 clinical trials for a potential treatment for cystic fibrosis.

the faster we enroll people in this trial, the faster this medication will get to the market if it's proven effective.

it's time to enroll, my fellow CFer's. let's make this happen!!!!!

Vertex Pharmaceuticals Inc. has launched Phase 3 clinical trials for a potential treatment for cystic fibrosis.

The primary trial for the drug candidate, called VX-770, will be a 48-week trial that is open to patients aged 12 years and older, and two additional trials will be open to patients between the ages of 6 and 11 years.

The drug candidate targets a defective protein that is thought to cause the disease, and is designed to improve lung function. The primary trial is seeking to enroll at least 80 patients, and registration is expected to be complete in the first quarter of 2010.

VX-770 was discovered as part of a collaboration with Cystic Fibrosis Foundation Therapeutics Inc., the nonprofit drug discovery and development affiliate of the Cystic Fibrosis Foundation.

The Foundation has invested more than $320 million in drug research in the biotech industry since 1998.

Vertex retains worldwide rights to develop and commercialize the drug, if it gains regulatory approval.

Cystic fibrosis is a life-threatening genetic disease affecting approximately 30,000 people in the United States and 70,000 people worldwide. The median-predicted age of survival for a person with Cystic Fibrosis is about 37 years.

Vertex (Nasdaq: VRTX) was trading at $29.69 a share in mid-morning trading Wednesday, up from the previous day’s close of $29.62 a share.

Participating sites in this Phase III trial for 12 years old and up are:

Locations

United States, Alabama
	Not yet recruiting
Birmingham, Alabama, United States
United States, California
	Not yet recruiting
Palo Alto, California, United States
	Not yet recruiting
San Diego, California, United States
	Not yet recruiting
Oakland, California, United States
United States, Colorado
	Not yet recruiting
Denver, Colorado, United States
United States, Idaho
	Not yet recruiting
Boise, Idaho, United States
United States, Illinois
	Not yet recruiting
Chicago, Illinois, United States
United States, Indiana
	Not yet recruiting
Indianapolis, Indiana, United States
	Not yet recruiting
Bloomington, Indiana, United States
United States, Iowa
	Not yet recruiting
Iowa City, Iowa, United States
United States, Kentucky
	Not yet recruiting
Lexington, Kentucky, United States
United States, Maryland
	Not yet recruiting
Baltimore, Maryland, United States
United States, Massachusetts
	Not yet recruiting
Boston, Massachusetts, United States
United States, Michigan
	Not yet recruiting
Grand Rapids, Michigan, United States
	Not yet recruiting
Ann Arbor, Michigan, United States
	Not yet recruiting
Detroit, Michigan, United States
United States, Minnesota
	Not yet recruiting
Minneapolis, Minnesota, United States
United States, Missouri
	Not yet recruiting
St. Louis, Missouri, United States
United States, Nebraska
	Not yet recruiting
Lincoln, Nebraska, United States
United States, New Jersey
	Not yet recruiting
Long Branch, New Jersey, United States
United States, New York
	Not yet recruiting
Syracuse, New York, United States
	Recruiting
Buffalo, New York, United States
	Not yet recruiting
New Hyde Park, New York, United States
United States, North Carolina
	Not yet recruiting
Chapel Hill, North Carolina, United States
United States, Ohio
	Not yet recruiting
Cleveland, Ohio, United States
	Not yet recruiting
Columbus, Ohio, United States
	Not yet recruiting
Toledo, Ohio, United States
	Not yet recruiting
Cincinnati, Ohio, United States
United States, Oregon
	Not yet recruiting
Portland, Oregon, United States
United States, Pennsylvania
	Not yet recruiting
Hershey, Pennsylvania, United States
	Not yet recruiting
Pittsburgh, Pennsylvania, United States
	Not yet recruiting
Philadelphia, Pennsylvania, United States
United States, Tennessee
	Not yet recruiting
Nashville, Tennessee, United States
	Not yet recruiting
Knoxville, Tennessee, United States
United States, Texas
	Not yet recruiting
Houston, Texas, United States
United States, Utah
	Not yet recruiting
Salt Lake City, Utah, United States
United States, Virginia
	Not yet recruiting
Charlottesville, Virginia, United States
United States, Washington
	Not yet recruiting
Seattle, Washington, United States
United States, West Virginia
	Not yet recruiting
Morgantown, West Virginia, United States
United States, Wisconsin
	Not yet recruiting
Milwaukee, Wisconsin, United States
Australia, New South Wales
	Not yet recruiting
Westmead, New South Wales, Australia
Australia, Queensland
	Not yet recruiting
Herston, Queensland, Australia
	Not yet recruiting
South Brisbane, Queensland, Australia
	Not yet recruiting
Brisbane, Queensland, Australia
Australia, Victoria
	Not yet recruiting
Parkville, Victoria, Australia
Canada, Alberta
	Not yet recruiting
Calgary, Alberta, Canada
Canada, British Columbia
	Not yet recruiting
Vancouver, British Columbia, Canada
Canada, Nova Scotia
	Not yet recruiting
Halifax, Nova Scotia, Canada
Canada, Ontario
	Not yet recruiting
Toronto, Ontario, Canada
Canada, Quebec
	Not yet recruiting
Montreal, Quebec, Canada
Czech Republic
	Not yet recruiting
Prague, Czech Republic
France
	Not yet recruiting
Paris, France
	Not yet recruiting
Brittany, France
Germany
	Not yet recruiting
Munich, Germany
	Not yet recruiting
Hannover, Germany
	Not yet recruiting
Wurzburg, Germany
	Not yet recruiting
Jena, Germany
	Not yet recruiting
Erlangen, Germany
Ireland
	Not yet recruiting
Dublin, Ireland
	Not yet recruiting
Cork, Ireland
United Kingdom
	Not yet recruiting
London, United Kingdom
	Not yet recruiting
Cambridge, United Kingdom
	Not yet recruiting
Birmingham, United Kingdom
United Kingdom, Northern Ireland
	Not yet recruiting
Belfast, Northern Ireland, United Kingdom Participating sites in this Phase III trial for 6- 11 years old are United States, Alabama Birmingham, Alabama, United States United States, Illinois Chicago, Illinois, United States United States, Indiana Indianapolis, Indiana, United States United States, Kentucky Lexington, Kentucky, United States United States, Massachusetts Boston, Massachusetts, United States United States, Michigan Ann Arbor, Michigan, United States Detroit, Michigan, United States United States, Minnesota Minneapolis, Minnesota, United States United States, Nebraska Lincoln, Nebraska, United States United States, Ohio Columbus, Ohio, United States United States, Pennsylvania Hershey, Pennsylvania, United States Pittsburgh, Pennsylvania, United States United States, Tennessee Knoxville, Tennessee, United States United States, Utah Salt Lake City, Utah, United States United States, Virginia Charlottesville, Virginia, United States Canada, British Columbia Vancouver, British Columbia, Canada Canada, Ontario Toronto, Ontario, Canada Canada, Quebec Montreal, Quebec, Canada France Paris, France Germany Jena, Germany Ireland Dublin, Ireland Cork, Ireland United Kingdom London, United Kingdom

Importance of DNase and alginate lyase for enhancing free and liposome encapsulated aminoglycoside activity against Pseudomonas aeruginosa

J Antimicrob Chemother. 2009 May 22.

Importance of DNase and alginate lyase for enhancing free and liposome encapsulated aminoglycoside activity against Pseudomonas aeruginosa.

Alipour M, Suntres ZE, Omri A.

The Novel Drug & Vaccine Delivery Systems Facility, Department of Chemistry and Biochemistry, Laurentian University, Sudbury, Ontario, P3E 2C6, Canada.

Objectives This study evaluated the potential of DNase, alginate lyase (AlgL) and N-acetylcysteine (NAC) in enhancing the in vitro bactericidal activity of conventional (free) and vesicle-entrapped (liposomal) gentamicin, amikacin and tobramycin.

Methods The MICs and biofilm eradication for two clinical isolates of Pseudomonas aeruginosa (a mucoid strain and a non-mucoid strain) were determined in the presence and absence of AlgL. The co-activity of aminoglycosides with DNase and/or AlgL against endogenous P. aeruginosa in cystic fibrosis (CF) sputum was also measured. The inhibitory effects of mucin in the presence and absence of the mucolytic agent NAC on aminoglycosidic activity were also examined.

Results The MIC values of the liposomal aminoglycosides were similar to or lower than those of free aminoglycosides. Biofilm formation increased the bactericidal concentrations of these drugs by 8- to 256-fold and treatment with AlgL improved killing of the mucoid strain. The activity of some aminoglycosides against the sputum was increased by the addition of DNase or AlgL (P <> 0.05). Tobramycin was the most effective aminoglycoside to reduce biofilms and sputum.

Conclusions Liposomal aminoglycosides do not fare better than conventional forms. The co-administration of DNase and AlgL is essential for enhanced activity in reducing biofilm growth and sputum bacterial counts. While mucin retards bactericidal activity, NAC does not improve aminoglycosidic activity.

Treatment of Acne with Oral Isotretinoin in Patients with Cystic Fibrosis.

Arch Dis Child. 2009 May 21. [Epub ahead of print]

Treatment of Acne with Oral Isotretinoin in Patients with Cystic Fibrosis.

Perera E, Massie J, Phillips RJ.

Royal Children's Hospital, Australia.

BACKGROUND: Theoretical concerns about liver disease and vitamin A deficiency have limited the use of oral isotretinoin for troublesome acne in adolescents with cystic fibrosis.

METHODS: We administered oral isotretinoin to 9 patients with cystic fibrosis who had troublesome acne unresponsive to antibiotics. All patients were followed for 1-4 years after cessation of treatment.

RESULTS: Isotretinoin treatment cleared active acne lesions in all patients. It was well tolerated and no patient had significant side effects. All nine patients were pleased or delighted with the improvement in their skin.

CONCLUSIONS: Adolescents with cystic fibrosis and acne can be treated with oral isotretinoin. Oral isotretinoin should be considered for adolescents with cystic fibrosis who have acne associated with scarring, acne not clearing with topical and antibiotic treatment, acne associated with depression, or severe cystic acne.

PMID: 19465582 [PubMed - as supplied by publisher]

Association of MBL2, TGF-β1 and CD14 gene polymorphisms with lung disease severity in cystic fibrosis

Jornal Brasileiro de Pneumologia

versionPrint ISSN 1806-3713

J. bras. pneumol. vol.35 no.4 São Paulo Apr. 2009

doi: 10.1590/S1806-37132009000400007

ORIGINAL ARTICLE

Association of MBL2, TGF-β1 and CD14 gene polymorphisms with lung disease severity in cystic fibrosis^*

Elisangela Jacinto de Faria^I; Isabel Cristina Jacinto de Faria^II; José Dirceu Ribeiro^III; Antônio Fernando Ribeiro^IV; Gabriel Hessel^V; Carmen Sílvia Bertuzzo^VI

^IPhD in Medical Sciences. Universidade Estadual de Campinas - Unicamp, State University at Campinas - School of Medical Sciences, Campinas, Brazil
^IIPhD in Medical Sciences. Universidade Estadual de Campinas - Unicamp, State University at Campinas - School of Medical Sciences, Campinas, Brazil
^IIITenured Professor. Department of Pediatrics, Universidade Estadual de Campinas - Unicamp, State University at Campinas - School of Medical Sciences, Campinas, Brazil
^IVTenured Professor of Pediatric Gastroenterology. Universidade Estadual de Campinas - Unicamp, State University at Campinas - School of Medical Sciences, Campinas, Brazil
^VTenured Professor of Pediatric Gastroenterology. Universidade Estadual de Campinas - Unicamp, State University at Campinas - School of Medical Sciences, Campinas, Brazil
^VITenured Professor. Department of Medical Genetics, Universidade Estadual de Campinas - Unicamp, State University at Campinas - School of Medical Sciences, Campinas, Brazil

Correspondence to

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ABSTRACT

OBJECTIVE: To identify associations between genetic polymorphisms (in the MBL2, TGF-β1 and CD14 genes) and the severity of the lung disease in patients with cystic fibrosis (CF), as well as between the presence of ΔF508 alleles and lung disease severity in such patients.
METHODS: This was a cross-sectional cohort study, based on clinical and laboratory data, involving 105 patients with CF treated at a university hospital in the 2005-2006 period. We included 202 healthy blood donors as controls for the determination of TGF-β1 and CD14 gene polymorphisms. Polymorphisms in the MBL2 and TGF-β1 genes at codon 10, position +869, were genotyped using the allele-specific PCR technique. The C-159T polymorphism in the CD14 gene was genotyped using PCR and enzymatic digestion.
RESULTS: Of the 105 CF patients evaluated, 67 presented with severe lung disease according to the Shwachman score. The MBL2 gene polymorphisms were not associated with disease severity in the CF patients. Analysis of the T869C polymorphism in the TGF-β1 gene showed an association only between TC heterozygotes and mild pulmonary disease. Although patients presenting the TT genotype of the C159T polymorphism in the CD14 gene predominated, there was no significant difference regarding lung disease severity.
CONCLUSIONS: There was an association between the TC genotype of the T869C polymorphism (TGF-β1) and mild pulmonary disease in CF patients. In the CD14 gene, the TT genotype seems to be a risk factor for pulmonary disease but is not a modulator of severity. We found no association between being a ΔF508 homozygote and presenting severe lung disease.

Keywords: Cystic fibrosis; Polymorphism, genetic; Severity of illness index; Mannose-binding lectin; Transforming growth factor beta.

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Introduction

Cystic fibrosis (CF) is an autosomal recessive disease caused by more than 1,600 mutations in the gene that encodes the cystic fibrosis transmembrane conductance regulator (CFTR) protein, located on the long arm of chromosome 7. These mutations are divided into six classes. There are classical and atypical CF phenotypes, depending principally on the class and type of mutation. The incidence rate is 1/2,500 newborns, whereas that of CF patients is 1/25.^(1-3)

Population studies involving large numbers of CF patients confirm the genotype-phenotype relationship, mainly for pancreatic manifestations, albeit minimal for pulmonary manifestations. Therefore, little is known regarding the genetic characteristics of the genotype-phenotype relationship in pulmonary manifestations. It is known that even individuals homozygous for a mutation of higher prevalence (ΔF508) present greater variability in the impairment and evolution of pulmonary disease.⁽⁴⁾

Although environmental influences can interfere with pulmonary clinical manifestations, the possibility of an additional genetic variation, such as the presence of modifying genes, has been described, contributing to the final clinical expression in each patient. Some authors have reported that polymorphisms in genes other than CFTR can modify pulmonary disease severity in CF.⁽⁵⁾

A study in monozygotic twins has shown a higher concordance in relation to pulmonary disease severity when compared with the severity in dizygotic twins, suggesting a strong genetic contribution to the variability of pulmonary disease severity in CF patients.⁽⁶⁾

Modifying genes, with the exception of the CFTR gene, can influence phenotype severity in CF patients through a number of mechanisms, being able to modulate the phenotype alternating the conduction of chlorine; to regulate the splicing and the expression of the CFTR gene; and to modulate the susceptibility to bacterial infection and inflammatory response in the lungs. In addition, lung disease in CF patients can be modified by genes associated with mucociliary clearance, as well as by those associated with damage to and repair of the epithelial tissue.⁽⁷⁾

The concept of multiple genetic modifiers in Mendelian diseases, such as CF, is different from the concept of multiple genetic variants in non-Mendelian diseases, such as asthma. In complex genetic diseases, such as asthma, multiple genetic variants interact among themselves and the environment, causing the disease. Nevertheless, CF, being a Mendelian disease, is caused by mutations in the CFTR gene and there are genetic variations not connected to the CFTR gene, which may be unfavorable or favorable, and which modify phenotype severity together with environmental factors. In fact, genetic polymorphisms, whether or not they have effects in healthy subjects, can be modifiers in CF.⁽⁴⁾

Identifying the consequence of the action of modifying genes will allow better understanding of physiopathological aspects and of the genotype-phenotype relationship, as well as maximizing the treatment of patients with CF.⁽⁸⁾

Among modifying genes, the following can be found:

• MBL2: Located on the q11.2-q21arm of chromosome 10, MBL2 encodes the mannose-binding lectin (MBL) protein. It is a plasmatic protein with an important role in the innate defense system, which constitutes the first activation component of the complement system lectin pathway and acts in the neutralization of pathogenic microorganisms by an independent antibody mechanism.⁽⁹⁾ Its deficiency has been correlated with decreased pulmonary function in CF patients.

• TGF-β1: The TGF-β1 gene has been mapped to chromosome 19q13.1-q13.3. This gene is expressed in endothelial cells, hematopoietic cells and cells of related tissues. The TGF-β1 gene encodes the protein of TGF-β1, which is a member of a family of growing and differentiation factors, with multiple functions in a variety of different organic systems. The TGF-β1 protein is notable for its capacity of modulating a variety of cellular functions, including cell proliferation, differentiation and in vivo and in vitro apoptosis.⁽¹⁰⁾ Underexpression and overexpression of this protein can both cause damage to the respiratory tract.

• CD14: The CD14 gene is located on chromosome5q31.1, with 3,900 bp. It presents two exons and encodes a protein of 375 amino acids, being expressed at the border of the macrophage, monocyte and neutrophil membranes. It functions as a receptor for lipopolysaccharides, components of the external membrane of gram-negative bacteria. It is a constitutive element of the cell wall of Pseudomonas aeruginosa, which has high immunogenic power.^(1,11) Underexpression of CD14 has been related to the early colonization of bacteria, including P. aeruginosa, in the lungs.

The objective of the present study was to determine how strongly lung disease severity in patients with CF correlates with polymorphisms of exon 1 (codons 52, 54 and 57) and the promoter region (haplotypes HY, LY and LX) of the MBL2 gene, with T869C polymorphism in the TGF-β1 gene and with the C-159T polymorphism in the CD14 gene. We also evaluated the relationship between ΔF508 alleles and lung disease severity in CF patients.

Methods

This was a cross-sectional clinical and laboratory cohort study involving patients treated between 2005 and 2006 at the Cystic Fibrosis Outpatient Clinic of the Universidade Estadual de Campinas (Unicamp, Campinas State University) Department of Pediatrics and Hospital de Clínicas. We included all patients under follow-up treatment and who had been diagnosed with CF, confirmed based on clinical history and on at least two sweat tests with chlorine values equal to or above 60 mEq/L conducted through sweat stimulus by iontophoresis with pilocarpine,⁽¹²⁾ as well as on identification of genetic mutation.

We evaluated 105 CF patients, 67 of whom presented the clinical classification of lung disease. We included 202 healthy blood donors as controls for the polymorphisms in the TGF-β1 and CD14 genes.

The study was approved by the Research Ethics Committee of the Unicamp School of Medical Sciences, and all of the legal guardians gave written informed consent.

The clinical criteria analyzed included pulmonary manifestations, digestive manifestations and the Shwachman score (SS).⁽¹³⁾ Laboratory evaluation included pulmonary function tests, determination of sodium/chlorine levels in sweat, chest X-ray and HRCT scan of the chest. The SS evaluates physical activity, physical examination findings, nutrition and the radiologic profile. For each item, the maximum score is 25 points; lower scores translating to poorer clinical status. The total score is graded as very mild (86-100), mild (71-85), moderate (56-70), severe (41-55) and extremely severe (40 or less). All patients were previously genotyped for the CFTR gene by the team of the Molecular Genetics Laboratory of the Hospital de Clínicas. The DNA was extracted through the PCR technique, and specific regions were amplified so that the following mutations could be analyzed: ΔF508, G542X, N1303K, G551D and R553X.

For the MBL analysis, DNA extraction from peripheral blood leukocytes was conducted.⁽¹⁴⁾ After DNA extraction, we sequenced specific primers, through which various amplification reactions were conducted. Each had an initiator capable of detecting an allele or group of alleles. Using the sequence-specific PCR primers, we genotyped 105 individuals for known mutations in the H and L promoter region at the position -550 (G-C)-located at 550 bp before the start of the transcription site, where the guanine-to-cytosine substitution occurs-and in the X and Y promoter region, in the -221 (G-C) position-located at 221 bp before the transcription start site, where the guanine-to-cytosine substitution occurs. The -550 and -221 polymorphisms in the promoter region form the HY, LY and LX haplotypes.

The codons 52, 54 and 57, located on exon 1, give rise to three variable alleles (designated D, B and C, respectively). The regular allele has been called A, and the variable D, B and C alleles are classified as O. The point mutations in the D, B and C alleles occurred, respectively, in the nucleotides 223 (C-T)-cytosine-to-thymine substitution-230 (G-A)-guanine-to-adenine substitution-and 239 (G-A)-guanine-to-adenine substitution.

For the analysis of the TGF-β1 gene, DNA was extracted from peripheral blood leukocytes.⁽¹⁴⁾ Following DNA extraction, we identified the TGF-β1 gene polymorphism, located on codon 10, position +869 (T-C)-thymine-to-cytosine substitution-through the technique called amplification refractory mutation system.

For the CD14 gene analysis, we conducted DNA extraction from peripheral blood leukocytes.⁽¹⁴⁾ After DNA extraction, the CD14 polymorphism (C-159T, cytosine-to-thymine substitution) was genotyped.

The methods, primer sequences and restriction enzymes used, as well as the size of the fragments generated by MBL2, TGF-β1 and CD14 gene polymorphisms, are described in Table 1.^(15-17)

The analysis of the results and associations between the variables in CF patients and those in the control group were made using the chi-square test and ORs. The difference between the groups was considered statistically significant when the value of the test applied was p <>

Results

We evaluated 105 CF patients (53 men and 52 women) who were under follow-up treatment at the Cystic Fibrosis Outpatient Clinic of the Unicamp Department of Pediatrics. The SS was applied in 67 patients. The patients presented a mean age of 7.8 ± 0.71 years; 101 (96%) were Caucasians, and 4 (4%) were Mulatto.

We evaluated 202 blood donors as controls for the polymorphisms in the TGF-β1 and CD14 gene. Of those 202 controls, 60 (79.2%) were White, 41 (20.3%) were Black, and 1 was Asian (0.5%); there were 117 males (58%) and 85 females (42%); and the mean age was 34 ± 11.3 years.

We studied the presence of ΔF508 alleles in relation to lung disease severity. We found the difference between the presence and absence of two ΔF508 alleles in terms of lung disease severity to be statistically significant among patients with severe CF. In such patients, the absence of ΔF508 alleles represented a risk factor (p = 0.1; OR = 16.29; variation, 1.43-787.09; Table 2).

In the analysis of polymorphisms at codons 52, 54 and 57 (AO alleles) of the MBL2 gene regarding the presence of ΔF508 alleles, our sample of CF patients was not found to be in Hardy-Weinberg equilibrium (HWE; χ₍₂₎² = 9.95; p = 0.007). No significant differences were observed in the analysis of these polymorphisms.

In the analysis of the H/L and X/Y polymorphisms in the promoter region of the MBL2 gene, regarding the presence of ΔF508 alleles, our sample of CF patients was found to be in HWE (χ₍₅₎² = 8.82; p = 0.11). No significant differences were observed in the analysis of these polymorphisms.

In the analysis of the T869C polymorphism in the TGF-β1 gene, the sample of CF patients was not found to be in HWE (χ₍₂₎² = 21.24; p = 0.000024). The control sample was found to be in HWE (χ₍₂₎² = 10.58; p = 0.005). In the genotypic comparison, there was a significant difference between CF patients and those in the control group in relation to the TC and CC genotypes, the TC genotype being identified as a risk factor (p = 0.01; OR = 2.00; variation, 1.11-3.61; Table 3).

In relation to the genotypic distribution of the T869C polymorphism in the TGF-β1 gene in control individuals, compared with CF patients, only one polymorphism was found to correlate significantly with lung disease (mild). The TC genotype (p = 0.01; OR = 4.07; variation, 1.16-21.78) was identified as a risk factor for mild lung disease in CF patients (Table 4).

In the analysis of the C159T polymorphism in the CD14 gene, the sample of CF patients was found to be in HWE: (χ₍₂₎² = 4.38; p = 0.11). The control sample is not in HWE (χ₍₂₎² = 18.72; p = 0.00008).

In the genotypic comparison, there was a significant difference between the group of CF patients and the control group regarding C159T polymorphism in the CD14 gene. The TT genotype was found to be a risk factor in the sample, but not a modulating factor of lung disease severity (p = 0.001; OR = 4.36; variation, 1.68-12.16; Table 5).

Discussion

Among COPDs, asthma and CF are phenotypically manifested as consequent to a genetic and an environmental component, which determine the severity and the clinical course over the lifetime of patients with these diseases.

In CF and asthma, we identified mutations in 1 and in more than 100 genes, respectively, characterizing the identification of many phenotypes in these two COPDs. We demonstrated, therefore, that the phenotypical complexity of asthma is higher than is that of CF. Nevertheless, whereas the association between polymorphisms and phenotypical manifestations has been widely studied in asthma, there have been few studies in CF.

After an extensive review of the literature, we can state that this is the first study in Brazil to determine the association between polymorphisms of the MBL2, TGF-β1 and CD14 genes and lung disease severity in children and teenagers with CF.

In the present study, for polymorphisms in which the control sample was not found to be in HWE, the probable explanation comes from the fact that, in the HWE guidelines, an ideal population, with no selective pressure, is recommended. In the case of the polymorphisms studied, since they influence mechanisms related to inflammation, it is possible that certain genotypes suffer from a selective pressure and, consequently, the genotypic distribution has not met the HWE criteria.

In CF, the pulmonary component can be influenced by genetic and environmental factors, as well as by modifying genes other than the CFTR gene.⁽¹⁸⁾

In contrast to the findings of other studies, in the analysis of pulmonary disease severity and of the presence of ΔF508 alleles, we identified fewer ΔF508/ΔF508 homozygotes among patients with severe lung disease, showing a lack of association between being ΔF508 homozygous and presenting greater lung disease severity.

In our sample of CF patients, MBL2 gene polymorphisms were not associated with lung disease severity. One possible explanation for our results is the fact that most patients were younger than 15 years of age. Some authors have shown that MBL deficiency is related to lung disease severity only in CF patients older than 15 years of age.⁽¹⁹⁾ In such patients, the growth hormone can significantly affect the level of circulating MBL. That study revealed significant age- and physical development-related differences among CF patients in terms of MBL and pulmonary function.⁽¹⁹⁾

Various authors have reported that only CF patients whose genotype is OO (homozygous for polymorphisms in exon 1 of the MBL2 gene), which is related to the low production of MBL protein, present a decrease in pulmonary function.^(20,21) The same was not observed in another study in which the two MBL2 gene genotypes-AO (heterozygote) and OO (homozygote)-were associated with a decrease in pulmonary function.^(22,23)

It has been shown that children diagnosed with CF colonized by P. aeruginosa and who are MBL deficient have more severe pulmonary dysfunction in comparison with those presenting intermediate or high levels of circulating MBL.⁽²⁴⁾ The authors have shown that these modulating effects are due to the high production of the TGF-β protein, suggesting a complex gene-gene interaction between MBL2 and TGF-β1.⁽²⁴⁾

Studies of MBL deficiency and colonization by P. aeruginosa have yielded promising results and should be carried out in Brazil. We believe that multiple genetic factors can influence the response that MBL deficiency performs as a function, due to the variable alleles of this protein. It is known that MBL exerts a complex effect on the inflammatory response at the pulmonary level.

In relation to the T869C polymorphism in the TGF-β1 gene, in our study, we found an association only between the TC heterozygote and mild lung disease.

Two studies have shown that CF patients with the TT genotype (low protein production) at codon 10 of the TGF-β1 gene are at high risk for pulmonary disease.^(25,26) In contrast, another group of authors found that the CC genotype (high protein production) is that which presented a high risk for the deterioration of the pulmonary function.⁽⁵⁾

Positive associations between airway colonizations by different bacteria and the production of the TGF-β1 protein have been demonstrated.

The decreased or increased production of the TGF-β1 protein in CF patients, colonized, respectively, by Burkholderia cepacia and P. aeruginosa, identifies the importance of the production of this regulatory cytosine in different bacterial colonizations and in CF severity.⁽²⁷⁾

The variation found in studies related to TGF-β1 genotypes with lung disease severity may be explained by genotypic differences, by the number of patients, as well as by uncontrolled environmental aspects, among the groups of the few studies published.

In the present study, detection of the C159T polymorphism in the CD14 gene revealed a predominance of CF patients with the TT genotype (increase in the production of the CD14 protein), although there were no differences in relation to lung disease severity.

In one study, the CD14-159CC polymorphism was found to be associated with the early colonization of airways by P. aeruginosa in children with CF. These children presented decreased plasma levels of the soluble CD14 protein, together with an inappropriate pro-inflammatory response.⁽¹¹⁾

Although children with high plasma levels of the soluble CD14 protein might be relatively protected against early colonization by P. aeruginosa, when becoming colonized, they may have a more intense inflammatory response.

Since ethnic and racial differences are common in polymorphic systems, inducing the expression of a clinical phenotype in different populations, it is possible that different results would be found in other populations and racial groups.

The results obtained in the present study allow us to conclude that many questions remain regarding the function of the modifying genes in CF in different populations. Therefore, multicenter studies, evaluating a larger number of patients in each mutation class, are necessary for understanding the effects of modifying genes in CF.

Acknowledgements

The authors would like to thank the members of the multidisciplinary team of the Cystic Fibrosis Outpatient Clinic of the State University at Campinas Hospital das Clínicas.

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Correspondence to:
Elisangela Jacinto de Faria
Caixa Postal 6111, Cidade Universitária Zeferino Vaz
CEP 13083-970, Campinas, SP, Brasil
Tel 55 19 3252-2603
E-mail: elliiss@yahoo.com.br

Submitted: 20 August 2008.
Accepted, after review: 17 September 2008.
Financial support: None.

* Study carried out in the Department of Medical Genetics, Universidade Estadual de Campinas - Unicamp, State University at Campinas - School of Medical Sciences, Campinas, Brazil.

© 2009 Sociedade Brasileira de Pneumologia e Tisiologia

SEPS 714/914, Bloco E, Asa Sul, salas 220/223
70390-145 Brasília DF Brasil
Tel.: +55 61 3245-1030 / 3245-6218

Comparison Between RTX (Biphasic Cuirass Ventilator) and Physiotherapy in Cystic Fibrosis Patients

Comparison Between RTX (Biphasic Cuirass Ventilator) and Physiotherapy in Cystic Fibrosis Patients


Israel


http://www.clinicaltrials.gov/ct2/show/NCT00908505?term=cystic+fibrosis&recr=Open

Soon to enroll: Effects of Mycophenolate Mofetil in Cystic Fibrosis Lung Transplant Patients

Effects of Mycophenolate Mofetil in Cystic Fibrosis Lung Transplant Patients


Michigan


' Purpose

Lung transplantation is a life saving procedure for patients with a terminal lung disease such as cystic fibrosis. Approximately, one in 3,500 children in the United States are born with cystic fibrosis each year with the predicted survival reaching 36.9 years in 2006. Cystic fibrosis was the third lead indication for lung transplantation in 2006. Cystic fibrosis is a genetic disease that can affect the way the body can remove salt from various organs.

It results in mucus blocking the ducts of the lungs and pancreas leading to inability to handle oxygen and malabsorption of nutrients. Malabsorption is a common complication of cystic fibrosis that can affect the way the anti-rejection medications are absorbed. One medication that is utilized after transplant to prevent rejection is mycophenolate mofetil. This medication may not be absorbed adequately in this population due to their disease thus placing these patients at increased risk of rejection. At the investigators' institution, all transplant patients are initiated at the same mycophenolate dose regardless of their underlying disease. The limited available literature regarding cystic fibrosis transplant patients and mycophenolate suggests that these patients require higher doses due to their erratic absorption. The purpose of this study is to evaluate the effects of mycophenolate mofetil on the body in lung transplant patients who have cystic fibrosis in efforts to improve survival outcomes.

Condition	Intervention
Cystic Fibrosis Lung Transplant Patients	Drug: mycophenolate mofetil

http://www.clinicaltrials.gov/ct2/show/NCT00908830?term=cystic+fibrosis&recr=Open