Inhaled Dry Powder Mannitol Improves Lung Function In CF

Adding inhaled dry powder mannitol to standard therapy for cystic fibrosis produced sustained improvement in lung function for up to 52 weeks, according to a new study. Along with the treatment's efficacy and good safety profile, the convenience and ease of administration of mannitol treatment may improve adherence with therapy in these patients.

In the double-blind study, which was supported by Pharmaxis Limited, 318 patients were randomized to treatment with 400 mg bid inhaled mannitol or 50 mg bid inhaled mannitol (control group) for 26 weeks, followed by an additional 26 weeks of open-label active treatment. A 50 mg dose was chosen as the control because it was felt it would not be clinically effective, based on an earlier dose escalation study. Mannitol was given on top of a background of typical concomitant therapy such as recombinant human deoxyribonuclease and inhaled antibiotics.

The findings were published online ahead of print publication in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine.

"Patients in the treatment group showed a 106.5 mL mean improvement in forced expiratory volume in one second (FEV1), an 8.22 percent improvement from baseline, compared with a 52.4 mL improvement (4.47 percent) in the control group," said lead author Moira L. Aitken, MD, professor of pulmonary and critical care medicine at the University of Washington Medical Center. "Forced vital capacity increased 136.3 mL in the treatment group, compared with 65.0 mL in the control group. Treated patients also experienced fewer pulmonary exacerbations than controls."

The difference in absolute FEV1 between the study and control groups approached statistical significance (p=0.059), while the difference in relative change from baseline FEV1 between groups reached significance (p=0.029). Improvements in FEV1 were maintained in the treatment group during the 26-week open-label extension phase of the study. In the control group, mean FEV1 improved 84.0 mL (6.3 percent) from baseline during the open-label phase.

Patients in the treatment and control groups experienced similar rates of adverse events. Given a possible influence of mannitol on lung microbiology, qualitative sputum microbiology was performed for Staphylococcus aureus and Pseudomonas aeruginosa during the double-blind study period. No qualitative changes in microbiology results from baseline were observed in either group.

Compliance was good in both groups, with 85.2 percent of patients in the treatment group and 88.7 percent of controls using 60 percent or more of the drug dispensed.

Although the primary end point for the study, the difference in absolute FEV1 between the treatment and control groups, did not reach significance, this may have been due to use of a single baseline visit to establish baseline FEV1 values. When baseline FEV1 values were calculated as an average of FEV1 values over two baseline visits, as in prior clinical intervention studies, the overall increase in absolute FEV1 was significantly (p=0.0008) greater in the treatment group. The 50 mg dose of mannitol used in the control group may also have had some benefit, which limited the absolute difference between groups.

"In our patients with cystic fibrosis, treatment with inhaled mannitol resulted in sustained improvements in lung function over 12 months, with a favorable safety profile," concluded Dr. Aitken. "In addition, the dry-powder inhaler used to administer mannitol is small, portable, easy to use and doesn't require thorough cleaning and disinfection after each use, which may help patients better adhere to treatment. Our results support the use of inhaled mannitol for the daily management of cystic fibrosis."

Lung Function In CF Improved By Long-Term Inhaled Dry Powder Mannitol

Adding inhaled dry powder mannitol to standard therapy for cystic fibrosis produced sustained improvement in lung function for up to 52 weeks, according to a new study. Along with the treatment's efficacy and good safety profile, the convenience and ease of administration of mannitol treatment may improve adherence with therapy in these patients.

In the double-blind study, which was supported by Pharmaxis Limited, 318 patients were randomized to treatment with 400 mg bid inhaled mannitol or 50 mg bid inhaled mannitol (control group) for 26 weeks, followed by an additional 26 weeks of open-label active treatment. A 50 mg dose was chosen as the control because it was felt it would not be clinically effective, based on an earlier dose escalation study. Mannitol was given on top of a background of typical concomitant therapy such as recombinant human deoxyribonuclease and inhaled antibiotics.

The findings were published online ahead of print publication in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine.

"Patients in the treatment group showed a 106.5 mL mean improvement in forced expiratory volume in one second (FEV1), an 8.22 percent improvement from baseline, compared with a 52.4 mL improvement (4.47 percent) in the control group," said lead author Moira L. Aitken, MD, professor of pulmonary and critical care medicine at the University of Washington Medical Center. "Forced vital capacity increased 136.3 mL in the treatment group, compared with 65.0 mL in the control group. Treated patients also experienced fewer pulmonary exacerbations than controls."

The difference in absolute FEV1 between the study and control groups approached statistical significance (p=0.059), while the difference in relative change from baseline FEV1 between groups reached significance (p=0.029). Improvements in FEV1 were maintained in the treatment group during the 26-week open-label extension phase of the study. In the control group, mean FEV1 improved 84.0 mL (6.3 percent) from baseline during the open-label phase.

Patients in the treatment and control groups experienced similar rates of adverse events. Given a possible influence of mannitol on lung microbiology, qualitative sputum microbiology was performed for Staphylococcus aureus and Pseudomonas aeruginosa during the double-blind study period. No qualitative changes in microbiology results from baseline were observed in either group.

Compliance was good in both groups, with 85.2 percent of patients in the treatment group and 88.7 percent of controls using 60 percent or more of the drug dispensed.

Although the primary end point for the study, the difference in absolute FEV1 between the treatment and control groups, did not reach significance, this may have been due to use of a single baseline visit to establish baseline FEV1 values. When baseline FEV1 values were calculated as an average of FEV1 values over two baseline visits, as in prior clinical intervention studies, the overall increase in absolute FEV1 was significantly (p=0.0008) greater in the treatment group. The 50 mg dose of mannitol used in the control group may also have had some benefit, which limited the absolute difference between groups.

"In our patients with cystic fibrosis, treatment with inhaled mannitol resulted in sustained improvements in lung function over 12 months, with a favorable safety profile," concluded Dr. Aitken. "In addition, the dry-powder inhaler used to administer mannitol is small, portable, easy to use and doesn't require thorough cleaning and disinfection after each use, which may help patients better adhere to treatment. Our results support the use of inhaled mannitol for the daily management of cystic fibrosis."

Cystic Fibrosis - Inhaling Mannitol Plus Standard therapy Improves Lung Function

A new study found that the combination of inhaled dry powder mannitol with standard therapy for cystic fibrosis resulted in maintained improvement in lung function for 12 months. In addition to being effective and safe, the easy administration of the treatment might help enhance adherence with treatment in individuals suffering with the condition. The study, supported by Pharmaxis Limited, is published online ahead of print publication in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine.

The researchers enrolled 318 patients to participate in the double-blind study. Participants were then randomly assigned to receive either 400mg bid inhaled mannitol or 50 mg big inhaled mannitol (control group) for 26 weeks, followed by an additional 26 weeks of open-label active treatment. The researchers chose 50 mg dose for the control group as they believed it would not be clinically effective, based on a previous dose escalation investigation. Mannitol was given in addition to typical concomitant therapy, such as inhaled antibiotics and recombinant human deoxyribonuclease.

Lead researcher Moira L Aitken, MD, professor of pulmonary and critical care medicine at the University of Washington Medical Center, explained:

"Patients in the treatment group showed a 106.5 mL mean improvement in forced expiratory volume in one second (FEV1), an 8.22 percent improvement from baseline, compared with a 52.4 mL improvement (4.47 percent) in the control group. Forced vital capacity increased 136.3 mL in the treatment group, compared with 65.0 mL in the control group. Treated patients also experienced fewer pulmonary exacerbations than controls."

Between the treatment and control groups the difference in absolute FEV1 reached statistical significance (p=0.059), while the difference in relative change from baseline FEV1 reached significance (p=0.029). Participants in the treatment group maintained FEV1 improvements during the 26-week open-label phase of the investigation. From the start of the investigation to during the open-label phase, mean FEV1 improved 84.0 mL (6.3%) in the control group.

Both groups experienced comparable rates of side effects. During the study phase, qualitative sputum microbiology was performed for Staphylococcus aureus and Pseudomonas aeruginosa, due to potential influence of mannitol on lung microbiology. In both groups the researchers did not observe any qualitative changes in microbiology results from baseline.

In both groups compliance to treatment was good, 85.2% of participants in the treatment group and 88.7% of those in the control group using 60% or more of the medication dispensed.

According to the researchers the primary end point for the investigation, the difference in absolute FEV1 between groups, did not achieve significance. They explain that use of a single baseline visit to establish baseline FEV1 values may be the cause of this. When the team calculated baseline FEV1 values as an average of FEV1 values over two baseline visits, as in previous clinical intervention investigations, the overall increase in absolute FEV1 in the treatment group was considerably greater (p=0.0008). Furthermore, the 50 mg dose patients received in the control group may have had some benefit, which restricted the absolute difference between the two groups.

Dr. Aitken concluded:

"In our patients with cystic fibrosis, treatment with inhaled mannitol resulted in sustained improvements in lung function over 12 months, with a favorable safety profile.

In addition, the dry-powder inhaler used to administer mannitol is small, portable, easy to use and doesn't require thorough cleaning and disinfection after each use, which may help patients better adhere to treatment. Our results support the use of inhaled mannitol for the daily management of cystic fibrosis."

Better Treatments For Systemic Fungal Infections May Result From Discovery Of Powerful Drug's Surprising, Simple Method

With one simple experiment, University of Illinois chemists have debunked a widely held misconception about an often-prescribed drug.

Led by chemistry professor and Howard Hughes Medical Institute early career scientist Martin Burke, the researchers demonstrated that the top drug for treating systemic fungal infections works by simply binding to a lipid molecule essential to yeast's physiology, a finding that could change the direction of drug development endeavors and could lead to better treatment not only for microbial infections but also for diseases caused by ion channel deficiencies.

"Dr. Burke's elegant approach to synthesizing amphotericin B, which has been used extensively as an antifungal for more than 50 years, has now allowed him to expose its elusive mode of action," said Miles Fabian, who oversees medicinal chemistry research grants at the National Institute of General Medical Sciences. The institute is part of the National Institutes of Health, which supported the work. "This work opens up avenues for improving upon current antifungals and developing novel approaches for the discovery of new agents."

Systemic fungal infections are a problem worldwide and affect patients whose immune systems have been compromised, such as the elderly, patients treated with chemotherapy or dialysis, and those with HIV or other immune disorders. A drug called amphotericin (pronounced AM-foe-TARE-uh-sin) has been medicine's best defense against fungal infections since its discovery in the 1950s. It effectively kills a broad spectrum of pathogenic fungi and yeast, and has eluded the resistance that has dogged other antibiotics despite its long history of use.

The downside? Amphotericin is highly toxic.

"When I was in my medical rotations, we called it 'ampho-terrible,' because it's an awful medicine for patients," said Burke, who has an M.D. in addition to a Ph.D. "But its capacity to form ion channels is fascinating. So my group asked, could we make it a better drug by making a derivative that's less toxic but still powerful? And what could it teach us about avoiding resistance in clinical medicine and possibly even replacing missing ion channels with small molecules? All of this depends upon understanding how it works, but up until now, it's been very enigmatic."

While amphotericin's efficacy is clear, the reasons for its remarkable infection-fighting ability remained uncertain. Doctors and researchers do know that amphotericin creates ion channels that permeate the cell membrane. Physicians have long assumed that this was the mechanism that killed the infection, and possibly the patient's cells as well. This widely accepted dogma appears in many scientific publications and textbooks.

However, several studies have shown that channel formation alone may not be the killing stroke. In fact, as Burke's group discovered, the mechanism is much simpler.

Amphotericin binds to a lipid molecule called ergosterol, prevalent in fungus and yeast cells, as the first step in forming the complexes that make ion channels. But Burke's group found that, to kill a cell, the drug doesn't need to create ion channels at all - it simply needs to bind up the cell's ergosterol.

Burke's group produced a derivative of amphotericin using a molecule synthesis method Burke pioneered called iterative cross-coupling (ICC), a way of building designer molecules using simple chemical "building blocks" called MIDA boronates joined together by one simple reaction. They created a derivative that could bind ergosterol but could not form ion channels, and tested it against the original amphotericin.

If the widely accepted model was true, and ion channel formation was the drug's primary antifungal action, then the derivative would not be able to wipe out a yeast colony. But the ergosterol-binding, non-channel-forming derivative was almost equally potent to natural amphotericin against both of the yeast cell lines the researchers tested, once of which is highly pathogenic in humans. The researchers detailed their findings in the journal Proceedings of the National Academy of Sciences.

"The results are all consistent with the same conclusion: In contrast to half a century of prior study and the textbook-classic model, amphotericin kills yeast by simply binding ergosterol," Burke said.

"The beauty is, because we now know this is the key mechanism, we can focus squarely on that goal. Now we can start to think about drug discovery programs targeting lipid binding."

The researchers currently are working to synthesize a derivative that will bind to ergosterol in yeast cells, but will not bind to cholesterol in human cells, to see if that could kill an infection without harming the patient. They also hope to explore other derivatives that would target lipids in fungi, bacteria and other microbes that are not present in human cells. Attacking these lipids could be a therapeutic strategy that may defy resistance.

In addition to exploiting amphotericin's lipid-binding properties for antimicrobial drugs, Burke and his group hope to harness its channel-creating ability to develop treatments for conditions caused by ion-channel deficiencies; for example, cystic fibrosis. These new findings suggest that the ion-channel mechanism could be decoupled from the cell-killing mechanism, thus enabling development of derivatives that could serve as "molecular prosthetics," replacing missing proteins in cell membranes with small-molecule surrogates.

"Now we have a road map to take ampho-terrible and turn it into ampho-terrific,"

Chemists Unlock Potential Target For Drug Development

A receptor found on blood platelets whose importance as a potential pharmaceutical target has long been questioned may in fact be fruitful in drug testing, according to new research from Michigan State University chemists.

A team led by Dana Spence of MSU's Department of Chemistry has revealed a way to isolate and test the receptor known as P2X1. By creating a new, simple method to study it after blood is drawn, the team has unlocked a potential new drug target for many diseases that impact red blood cells, such as diabetes, hypertension and cystic fibrosis.

Researchers can evaluate the receptor not only in developing new drugs but also re-testing existing medications that could work now by attaching to the receptor.

"Scientists are always looking for new 'druggable' receptors in the human body," Spence said. "This receptor, P2X1, has long been viewed as not important in platelets; our studies show that is not necessarily true. The receptor is very active; you just need to be careful in working with it."

The research is published in the current issue of Analytical Methods, a journal from the Royal Society of Chemistry in London.

The main job of platelets is to help prevent bleeding via clotting, Spence said. They work by getting sticky in the bloodstream, but the problem with some diseases such as diabetes or sickle-cell anemia is that the platelets get sticky even when they shouldn't, preventing proper blood flow and blocking vessels.

Platelets are activated when their receptors are "turned on"; currently, researchers have always focused on the P2Y receptor, which is easily studied. On the other hand, the P2X1 receptor was not thought to play a major role in platelet activation, and it proved very troublesome to study since it became desensitized once blood is drawn from the body, Spence said.

Though scientists tried a pair of methods to get around that issue - by using different additives or enzymes - the results did not prove fruitful in studying the receptor.

What Spence and his team found is that by adding a simple molecule called NF449 - originally thought to block the receptor - they were able to activate the P2X1 receptor in platelets after a blood draw.

"We have discovered a way to prepare and handle platelets so that we can study the receptor authentically," he said. "This research opens up new avenues of study and will allow researchers and pharmaceutical companies to re-appraise this receptor as a druggable target."

Early Cystic Fibrosis Detected Using Bronchoalveolar Lavage And Lung Clearance Index

According to a new Australian study published online before he print publication in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine, the lung clearance index (LCI) is a sensitive, non-invasive marker of early lung disease in young children with cystic fibrosis (CF).

Yvonne Belessis, MBBS, MPH, PhD, respiratory staff specialist at Sydney Children's Hospital declared:

"We found that LCI is elevated early in children with CF, especially in the presence of airway inflammation and Pseudomonas aeruginosa. LCI may not only be a marker of early CF lung disease, but may be useful as an objective outcome measure in future studies of young children with CF."

The researchers identified LCI following a multiple breath washout (MBW) conducted in 47 presymptomatic/minimally symptomatic infants and infants with CF with an average age of 1.55 years, and in 25 healthy controls aged on average 1.26 years. They also performed Bronchoalveolar lavage (BAL) in those suffering from cystic fibrosis.

The upper limit for a normal LCI was defined as 7.41. The findings revealed an average (SD) LCI in cystic fibrosis children with CF of 7.21 (0.81), as compared to 6.45 (0.49) in control children (P<.001). 15 (32%) from 47 CF children showed an elevated LCI. The researchers were able to repeat and reproduce all LCI measurements.

The findings also revealed that 17 (36%) children with CF, including 7 (15%) children with Pseudomonas aeruginosa infection suffered from an infection of the airway (≥105 cfu/mL BAL fluid). The results showed that LCI in children with Pseudomonas was 7.92 (1.16) and 7.02 (0.56) in those without this infection (P=.038). The researchers detected a substantial association between LCI and BAL inflammatory markers interleukin-8 and neutrophil count.

The researchers acknowledge the limitations of their study, which include the lack of a robust measure of structural lung disease and a higher diagnostic threshold for airway infection than used in other BAL studies.

Dr. Belessis concludes:

"We obtained reproducible measurements of LCI at the bedside of sedated infants and young children using a portable MBW system. Compared with healthy controls, LCI was elevated in well infants and young children with CF, and abnormal LCI was associated with Pseudomonas aeruginosa infection and airway inflammation. Our results show that the LCI is a feasible, sensitive and repeatable non-invasive marker of early lung disease in well infants and young children with CF. Longitudinal assessment of the LCI taking into consideration changes in inflammation and airway infection over time are needed to confirm these findings."

Bronchoalveolar Lavage And Lung Clearance Index Detects Early Cystic Fibrosis Lung Disease

The lung clearance index (LCI) is a sensitive non-invasive marker of early lung disease in young children with cystic fibrosis (CF), according to a new study from Australian researchers.

"We found that LCI is elevated early in children with CF, especially in the presence of airway inflammation and Pseudomonas aeruginosa," said Yvonne Belessis, MBBS, MPH, PhD, respiratory staff specialist at the Sydney Children's Hospital. "LCI may not only be a marker of early CF lung disease, but may be useful as an objective outcome measure in future studies of young children with CF."

The findings were published online ahead of print publication in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine.

LCI was determined after multiple breath washout (MBW) testing in 47 presymptomatic/minimally symptomatic infants and young children with CF (mean age 1.55 years) and 25 healthy control children (mean age 1.26 years). Bronchoalveolar lavage (BAL) was also performed in the children with CF.

Mean (SD) LCI in children with CF was 7.21 (0.81), compared with 6.45 (0.49) in control children (P<.001). The upper limit of normal for LCI was 7.41. Among the 47 children with CF, 15 (32%) had an elevated LCI. Measurements of LCI were repeatable and reproducible.

Airway infection (≥105 cfu/mL BAL fluid) was detected in 17 (36%) children with CF, including 7 (15%) children who had Pseudomonas aeruginosa infection. LCI in children with Pseudomonas was 7.92 (1.16), compared with 7.02 (0.56) in children without Pseudomonas (P=.038). LCI was significantly correlated with the BAL inflammatory markers interleukin-8 and neutrophil count.

There were some limitations to the study, including the lack of a robust measure of structural lung disease and a higher diagnostic threshold for airway infection than has been used in other BAL studies.

"We obtained reproducible measurements of LCI at the bedside of sedated infants and young children using a portable MBW system," said Dr. Belessis. "Compared with healthy controls, LCI was elevated in well infants and young children with CF, and abnormal LCI was associated with Pseudomonas aeruginosa infection and airway inflammation.

"Our results show that the LCI is a feasible, sensitive and repeatable non-invasive marker of early lung disease in well infants and young children with CF. Longitudinal assessment of the LCI taking into consideration changes in inflammation and airway infection over time are needed to confirm these findings."

Kalydeco - A Cystic Fibrosis Treatment

Kalydeco has been approved by the Food And Drug Administration (FDA) to treat a vicious type of Cystic Fibrosis (CF). CF is a deadly recessive disease which targets the lungs, but can also harm the liver, pancreas, and intestine. It occurs from the unusual transport of chloride and sodium across the epithelium, causing mucus buildup in the lungs, and thick secretions. In turn, many respiratory problems occur in patients with CF. Diabetes is also common among patients with CF and it is most common among Caucasians. This specific type of CF, which Kalydeco has been approved for, targets children 6 years of age and older who possess the G551D mutation in the Cystic Fibrosis Transmembrane Regulator (CFTR) gene.

Experts believe that of the 30,000 people who are affected in the United States by Cystic Fibrosis, an estimated 1,200 of them possess the G551D mutation. FDA Commissioner Margaret A. Hamburg, M.D comments:

Kalydeco is an excellent example of the promise of personalized medicine - targeted drugs that treat patients with a specific genetic makeup. The unique and mutually beneficial partnership that led to the approval of Kalydeco serves as a great model for what companies and patient groups can achieve if they collaborate on drug development."

Kalydeco was approved earlier than expected when reviewed by the FDA, after two 48-week placebo-controlled clinical studies had taken place. In the study, 213 patients were analyzed. One of the studies was conducted on patients 12 years of age and older, and the other on patients 6 to 11 years old. Both of the studies revealed the safety and effectiveness of Kalydeco. It had a great impact on improved lung function. The pill, when taken twice daily accompanying a food containing fat, is used to aid the protein made by the CFTR gene function more effectively, and therefore improves many of the signs and symptoms of CF, including rapid weight gain and lung function.

Jane Woodcock, M.D., director of the FDA's Center for Drug Evaluation and Research said:

Kalydeco is the first available treatment that targets the defective CFTR protein, which is the underlying cause of cystic fibrosis. This is a breakthrough therapy for the cystic fibrosis community because current therapies only treat the symptoms of this genetic disease.

The researchers explain that Kalydeco only works in patients with the G551D mutation, and does not work in the most common form of CF, which occurs in patients who have two copies of the F508 mutation in the CFTR gene. They say that an FDA approved test should be taken before patients with CF take Kalydeco, if their mutation status is unknown.

Kalydeco is manufactured by Vertex Pharmaceuticals Inc. of Cambridge Massachusetts and side effects of Kalydeco may occur. The most common are stomach aches, headaches, respiratory tract infection, diarrhea, rash, and dizziness.

New Research Could Provide Roadmap For More Effective Drug Discovery For Cystic Fibrosis

A recent study led by Gergely Lukacs, a professor at McGill University's Faculty of Medicine, Department of Physiology, and published in Cell, has shown that restoring normal function to the mutant gene product responsible for cystic fibrosis (CF) requires correcting two distinct structural defects. This finding could point to more effective therapeutic strategies for CF in the future.

CF, a fatal genetic disease that affects about 60,000 people worldwide, is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR), a membrane protein involved in ion and water transport across the cell surface. As such, CF is characterized by impaired chloride secretion causing the accumulation of viscous mucous that may cause multiple organ dysfunctions, including recurrent lung infection.

The most common mutation in CFTR, known as deltaF508, is caused by a single amino acid deletion and results in a misfolded version of CFTR that is retained within the cell and quickly degrades rather than being trafficked to the cell membrane where it would function as a chloride channel.

In 2005, Lukacs and his lab suggested that deltaF508 mutation effect is not restricted to the domain (the nucleotide binding domain 1 or NBD1, one of five building blocks of CFTR) where the deltaF508 is located. Specifically, his team found that the mutation destabilizes the NBD1 as well as the NBD2 architecture, suggesting that domain-domain interaction plays a critical role in both normal and pathological CFTR folding.

Building on his team's previous work and computer generated models of CFTR, Lukacs and his team set out to determine whether it was possible to correct both NBD1 stability and domain-domain interaction defect. Using a combination of biophysical, biochemical and genetic techniques, the team found that only simultaneous correction of both folding defects was able to ensure normal-like cell surface expression and function of the mutant.

"These findings offer a plausible explanation for the limited efficiency of the available correctors currently under clinical trial. If there are two different folding steps to correct, it is difficult to envision how a single drug could work," explained Lukacs. "The proposed two-step folding model points to the fact that the correction strategy has to be reconsidered."

Antibiotic Use For Cystic Fibrosis: Decade-Long Study Raises New Questions

When it comes to treating cystic fibrosis, the current standard of aggressive antibiotic treatments may not always be the best answer, a decade-long study led by researchers at the University of Michigan has found.

Traditionally, bacteria-blasting antibiotics are used to suppress infection in CF patients' lungs to the lowest level possible, but maintaining a diversity of bacterial communities may help some patients stay healthy longer, says the study's senior author, John J. LiPuma, M.D.

The findings appear in the Proceedings of the National Academy of Sciences.

"The conventional wisdom has been that as patients with CF age and become sicker, as their lung disease progresses, more and more bacteria move in," says LiPuma, the James L. Wilson, M.D., Research Professor of Pediatrics and Communicable Diseases at the U-M Medical School. "But our study - which was the first to examine the bacterial communities in CF patients' lungs over a long period of time - indicates that's not what happens."

Instead, aggressive use of antibiotics - rather than a patient's age or disease progression - is responsible for lowering the diversity of lung bacteria, leading to infections that become increasingly hard to treat. A diverse community of bacteria may encourage competition that keeps the most virulent strains in check, the researchers found.

"What we normally do is essentially carpet bombing with antibiotics," continues LiPuma, who is also an associate chair of the pediatrics department at U-M. "However, what we found is that over time this ultimately helps treatment-resistant bacteria by getting rid of their competition."

LiPuma says the results may mark a first step toward developing new therapeutic approaches, such as more narrowly tailored use of antibiotics or even a probiotic approach.

Cystic fibrosis is a chronic, life-threatening disease that leaves one vulnerable to repeated, ever-more-serious infections. It causes the body to produce thick, sticky mucus that clogs the lungs and provides the perfect breeding ground for bacteria. CF, which affects 30,000 people in the United States, is usually detected in early childhood and thanks to medical advances in recent decades, patients often survive into their 30s and 40s.

Even as bacterial diversity declines over time, the researchers found the overall level or "load" of bacteria remains fairly constant - meaning that as diversity declines, a small number of organisms multiply to take the place of those that have been destroyed.

Previous studies have collected samples from individual patients at a single point in time, which makes it difficult to examine relationships between the progression of the disease, antibiotic treatments and other variables, LiPuma explains. This study examined the bacteria from six patients collected over a period of eight to nine years. Three patients had a relatively stable type of the disease and three had the more typical, faster progressing form. DNA analysis was conducted on bacteria in 126 sputum samples.

The researchers were also surprised that exacerbations couldn't be linked to any specific changes in bacterial communities. Additional research is underway to look for more subtle signals that may precede or accompany flare ups, says LiPuma, who is also a professor of epidemiology at the U-M School of Public Health.

"Increasing our understanding of the relationship between bacteria in the lung and the progression of cystic fibrosis is critical to developing new treatments and prolonging patients' lives,"

Multiple Genes Linked To Differences In Cystic Fibrosis Identified

Cystic fibrosis (CF) is a devastating disease caused by mutations in the CFTR gene. In Canada, one in every 3,600 children born has the disease.

Researchers have long been puzzled as to how individuals who carry the same CFTR mutations can experience such different courses of disease. Patients with CF are affected in multiple organs such as the lungs, pancreas and liver, to varying degrees.

An international team led by The Hospital for Sick Children (SickKids) and the University for Toronto (U of T) has found a potential answer to this puzzle. The team has discovered multiple genes associated with meconium ileus, a severe intestinal obstruction present at birth in 15 per cent of patients with CF. The study is published online in Nature Genetics.

"Because meconium ileus is inherited, present at birth, and subject to limited environmental influence, it provides an ideal focus for identifying other contributors beyond CFTR that could result in differences in CF disease," says the study's principal investigator Dr. Lisa Strug, a Scientist in Child Health Evaluative Sciences at the SickKids Research Institute and an Assistant Professor at the Dalla Lana School of Public Health at the University of Toronto.

The team studied the genomes of almost 4,000 CF patients from the International Consortium in Gene Modifiers of CF. They developed and implemented a novel statistical technique that incorporated information about the causal CFTR gene to identify other CF-related genes. Multiple genes associated with developing meconium ileus were identified as a consequence, and some of these genes are anticipated to influence disease in other CF-affected organs.

"This work highlights the benefit of integrating statistical methodology with other disciplines in scientific studies," says Dr. Lei Sun, an Associate Professor at the Dalla Lana School of Public Health and the Department of Statistics at U of T. Sun shares first-authorship on the study with Dr. Johanna Rommens, a Scientist in Genetics & Genome Biology at SickKids Research Institute and a Professor of Molecular Genetics at U of T.

"In cystic fibrosis, CFTR does not function normally, which causes disease," says Strug. "Identifying other genes that influence the degree of organ-specific CF disease suggests the possibility of personalized approaches to treatment for individuals with CF, as well as novel therapeutic targets."

"We are proud to support Dr. Strug's important cystic fibrosis research, allowing us to advance treatment, and bring us closer to finding a cure," said Maureen Adamson, Chief Executive Officer at Cystic Fibrosis Canada. "Cystic Fibrosis Canada plays a leading role in the worldwide race for a cure. In 2012/13, we will invest more than $7.5 million in innovative research and clinical care for Canadians living with this devastating disease and will fund 51 research projects, six targeted programs and partnerships, and 47 fellows and students."

The Creation Of Lung Surface Tissue In A Dish Could Lead To Treatment For Cystic Fibrosis

Harvard stem cell researchers at Massachusetts General Hospital (MGH) have taken a critical step in making possible the discovery in the relatively near future of a drug to control cystic fibrosis (CF), a fatal lung disease that claims about 500 lives each year, with 1,000 new cases diagnosed annually.

Beginning with the skin cells of patients with CF, Jayaraj Rajagopal, MD, and colleagues first created induced pluripotent stem (iPS) cells, and then used those cells to create human disease-specific functioning lung epithelium, the tissue that lines the airways and is the site of the most lethal aspect of CF, where the genes cause irreversible lung disease and inexorable respiratory failure.

That tissue, which researchers now can grow in unlimited quantities in the laboratory, contains the delta-508 mutation, the gene responsible for about 70 percent of all CF cases and 90 percent of the ones in the United States. The tissue also contains the G551D mutation, a gene that is involved in about 2 percent of CF cases and the one cause of the disease for which there is now a drug.

The work is featured on the cover of this month's Cell Stem Cell journal, which appears online. Postdoctoral fellow Hongmei Mou, PhD, is first author on the paper, and Rajagopal is the senior author.

Mou credits learning the underlying developmental biology in mice as the key to making tremendous progress in only two years. "I was able to apply these lessons to the iPS cell systems," she said. "I was pleasantly surprised the research went so fast, and it makes me excited to think important things are within reach. It opens up the door to identifying new small molecules [drugs] to treat lung disease."

Doug Melton, PhD, co-director of the Harvard Stem Cell Institute, said, "This work makes it possible to produce millions of cells for drug screening, and for the first time human patients' cells can be used as the target." Melton, who is also co-chair of Harvard's inter-School Department of Stem Cell and Regenerative Biology and is the Xander University Professor, added, "I would expect to see rapid progress in this area now that human cells, the very cells that are defective in the disease, can be used for screening."

Rajagopal said, "The key to our success was the ecosystem of the Harvard Stem Cell Institute and MGH. HSCI investigators pioneered the strategies we used, helped us at the bench, and gave us advice on how to combine our knowledge of lung development with their exciting new platforms. Indeed, we also enjoyed a wonderful collaboration with Darrell Kotton's lab at Boston University that was able to convert mouse cells into lung tissue. These interactions really helped fuel us ahead."

The epithelial tissue created by Rajagopal and his colleagues at the MGH Center for Regenerative Medicine also provides researchers with the same cells that are involved in a number of common lung conditions, including asthma, lung cancer, and chronic bronchitis, and may hasten the development of new insights and treatments into those conditions as well.

"We're not talking about a cure for CF; we're talking about a drug that hits the major problem in the disease. This is the enabling technology that will allow that to happen in a matter of years," said Rajagopal, a Harvard Medical School assistant professor of Medicine.

Also a physician trained as a pulmonologist, the specialty that treats CF patients, Rajagopal said, "When we talk about research and advances, donors and patients ask: 'When? How soon?' And we usually hesitate to answer. But we now have every single piece we need for the final push. So I have every hope that we'll have a therapy in a matter of years."

Cystic fibrosis, which used to claim its victims in infancy or early childhood, has evolved into a killer of those in their 30s because treatments of the infections that characterize the disease have improved. But despite those advances, there has been little progress in treating the underlying condition that affects the vast majority of patients: a defect in a single gene that interferes with the fluid balance in the surface layers of the airways and leads to a thickening of mucus, difficulty breathing and repeated infections and hospitalizations.

The discovery and recent FDA approval of the drug Ivacaftor, which corrects the G551D defect seen in about 2 percent of CF patients, has served as a proof of concept to demonstrate that the disease can be attacked with a conventional molecular treatment. In fact, Ivacaftor was found by screening thousands of drugs on a far less than ideal cell line. In the end, many drugs that functioned well on this cell line proved ineffective when used on genuine human airway tissue.

Genuine human airway tissue is the gold standard prior to drugs being tested clinically, but it has been extremely difficult to obtain the tissue from patients, and when it could be obtained, the tissue rarely survived long in the lab - all of which created a major bottleneck in screening for a therapy. But by creating iPS cells that contain the entire genome of a CF patient and directing those cells to develop into lung progenitor cells, which then develop into epithelium, the group appears to have solved this key problem.

Rajagopal, who did his own postdoctoral fellowship in Melton's laboratory during the first half of the past decade after completing his training in pulmonary medicine, said that having both the G551D and 508 genes in the epithelial tissue provides a way to prove that the tissue will be effective in testing drugs against CF.

"We've created the perfect cell line to show that the drug out there that works against G551D mutation works in this system, and then we're in business to screen for a drug against delta 508," he said. "We'll know soon that the cell line works. We know it makes bonafide airway epithelium, and we'll have the proof of principle that the tissue responds properly to the only known drug. We think this is the near-ideal tissue platform to find a drug for the majority of CF."

Rajagopal's lab has created numerous other cell lines to further show that a CF drug that works in one patient should work in others and to see whether this will be an area that allows a more personalized approach to medicine.

"I'm most looking forward to working with the community of pulmonologists that concentrate in CF to generate therapies. This is occurring more than two decades after the remarkable work that identified the CF gene. Looking forward, I'm very excited that CF may lead the way in lung disease once more, by demonstrating that our iPS platform can be used to probe the diseases that are much less well understood. CF has more than two decades of great biology behind it. The reason we chose to attack this disease first was because of that pioneering work that lets us use our system with a very firm foundation," Rajagopal said.

Molecules Designed By Computer Point To New Therapy For Cystic Fibrosis

By developing software that uses 3-D models of proteins involved in cystic fibrosis, a team of scientists at Duke University has identified several new molecules that may ease the symptoms of the disease.

Computer algorithms created by the team predict how well a given molecular structure will block a basic protein-protein interaction known to occur in cystic fibrosis. To test the predictions, the scientists synthesized the molecules and measured how well they attached to one of the proteins in that interaction. The team then placed the best molecule into human cells with the cystic fibrosis mutation in a laboratory dish and found that their new drug blocked the protein-protein interaction and increased the cells' ability to balance salt and water levels.

The results, which appear in Public Library of Science Computational Biology, suggest that computers could make drug design for cystic fibrosis faster.

"We have known the genetic cause of cystic fibrosis since 1985. Now, by understanding its biology and chemistry, we can design and create targeted drugs to correct for the genetic flaw," said Bruce Donald, a Duke computer scientist and biochemist who led the study.

Cystic fibrosis, or CF, is a childhood disease causing the lungs and pancreas to fill with mucus, making it hard to breathe and absorb nutrients from food. The mucus builds in the organs as the levels of salt and water in the cells become unbalanced because of a defective protein.

That protein, called CFTR, the cystic fibrosis transmembrane conductance regulator, regulates salt and water in the cell. In CF, it is defective because the genes that generate it are mutated. CFTRs are routinely rounded up for recycling in the cell by a protein called CAL that binds to CFTR and hauls it away. But defective CFTR proteins in cystic fibrosis patients send a signal that they are faulty, making their recycling rate much higher.

Currently, no treatments exist to target the genetic mutations that cause cystic fibrosis. Scientists have discovered molecules that target CFTRs' defects, such as incorrect folding and fast recycling, and there are a few molecules that help correct how CFTR folds or slow down the CAL recycling truck. These molecules help keep copies of CFTR functioning in the cell membrane to maintain some balance between salt and water levels.

Donald and his graduate student Kyle Roberts thought that computer algorithms based on the structure of CAL and similar proteins could quickly generate several dozen more molecules for slowing recycling by CAL and increase the pool of potential cystic fibrosis treatments.

"Research shows that you only need a fraction of normal CFTR activity to alleviate cystic fibrosis symptoms, so keeping CFTR in the membrane by using our inhibitors could have a significant therapeutic effect," said Roberts, first author of the new study.

Donald and Roberts' algorithms searched several thousand potential inhibitors and ranked them based on how strongly it predicted each would bind with CAL. In collaboration with researchers at Dartmouth and in Germany, the scientists synthesized 11 of the highest-ranked sequences and used fluorescent light to measure each molecule's attachment to CAL.

The results show that many of the algorithm-generated molecules attach more strongly to CAL than the connection between CAL and CFTR in nature. The best computer-generated molecules also bind more efficiently to CAL than any previously reported inhibitor.

In a culture of human cells with the cystic fibrosis mutation, the best algorithm-generated inhibitor increased CFTR activity by 12 percent. Donald said the new molecule could be used in combination with another molecule, which corrects how CFTR proteins fold and raises CFTR's activity by 15 percent. The two molecules should work together and could increase CFTR's activity by about 27 percent, he said.

He cautioned that it could be several years before patients with the disease could use the new molecular combination as treatment because the molecules have not yet been tested in patients with the disease. The team has made its software freely available, Donald said, so the computer-design approach could quicken the pace at which molecules and resulting cystic fibrosis therapies are developed.

In Newborns With Cystic Fibrosis, Gene Variations Linked To Intestinal Blockage

University of North Carolina at Chapel Hill researchers working as part of the International Cystic Fibrosis Consortium have discovered several regions of the genome that may predispose cystic fibrosis (CF) patients to develop an intestinal blockage while still in the uterus.

A report of this international study appears online in the journal Nature Genetics. It was the work of the North America CF Gene Modifier Consortium, which brought together dozens of investigators from the United States, Canada, and from France, to identify genetic variations that could be linked with meconium ileus (MI), an intestinal obstruction that usually requires emergency surgery for treatment, and can result in a substantially increased rate of serious health problems.

MI affects roughly 15-20 percent of all patients with CF, a genetic condition that causes scarring throughout the body, especially the lungs and pancreas. Though every CF patient carries mutations in both copies of the same gene - coding for a protein called cystic fibrosis transmembrane conductance regulator, or CFTR - symptoms can vary widely from patient to patient.

The genome-wide association study (GWAS) of more than 3,700 CF patients identified non-CFTR genetic variants in the cell membrane that separates the interior of cells from the outside environment. More specifically, the variants involved genes responsible for ion transport in the lower end of the small intestine.

"These variants involve cells in the small intestine that predispose CF patients to develop MI while still in the womb," said one of the senior study authors Michael Knowles, MD, professor of pulmonary and critical care medicine at UNC and a member of UNC's Cystic Fibrosis-Pulmonary Research and Treatment Center.

"The discovery provides new understanding of the pathogenic mechanisms underlying MI. In addition, it offers the possibility of developing therapies to intervene in utero," Knowles said. "Further, it provides molecular insight into the role of genetic variation in ion transporters in CF, which may be applicable to more commonly, and severely, involved organs such as the lungs."

Why 1 Bacterial Infection Is So Deadly In Cystic Fibrosis

Scientists have found why a certain type of bacteria, harmless in healthy people, is so deadly to patients with cystic fibrosis.

The bacterium, Burkholderia cenocepacia, causes a severe and persistent lung infection in patients with CF and is resistant to nearly all known antibiotics. Cystic fibrosis is a chronic disorder characterized by a buildup of mucus in the lungs and other parts of the body, and various types of lung infection are responsible for about 85 percent of deaths in these patients.

The Ohio State University researchers have determined that B. cenocepacia bacteria interfere with an important survival process in cells whose job is to fight infection. This phenomenon is even stronger in CF patients, so the infection exacerbates the cell malfunction.

The research group also showed that rapamycin, an existing drug known to stimulate this cell-survival process, called autophagy, helped control B. cenocepacia infection in mice that serve as a model for cystic fibrosis.

The scientists also dissected the role of a molecule called p62, which plays a role in the autophagy process. They found that p62 inside macrophages, the cells that fight infection, is influential in controlling B. cenocepacia infection.

"This suggests that manipulating p62 levels might help patients with CF fight off the lethal infection," said Amal Amer, assistant professor of microbial infection and immunity and internal medicine at Ohio State and senior author of the study.

The research was presented at the American Society for Biochemistry and Molecular Biology annual meeting, which is held in conjunction with the Experimental Biology 2012 conference in San Diego. The rapamycin findings also were published in a recent issue of the journal Autophagy.

The B. cenocepacia infection remains relatively rare but highly transmissible in patients with cystic fibrosis. "It's really a death sentence for the patient. The disease either progresses with propagation of inflammation and chronic destruction of lung tissue, or acute infection with severe sepsis that occurs very quickly. We don't know which patient will take which course," said Amer, also an investigator in Ohio State's Center for Microbial Interface Biology.

Amer and her colleagues had been studying autophagy in other organisms before experimenting with these bacterial cells. Autophagy allows a cell to digest parts of itself to produce energy when it is experiencing starvation.

"We were among the first to show that autophagy can actually clear infection," Amer said. "So not only is it a physiological pathway in the background all the time, but some bacteria, when they infect cells, will be engulfed by autophagy. And that helps in clearing the infection."

These cells that can use autophagy to clear infection are the macrophages, which are first-responders in the immune system that essentially eat offending pathogens.

Amer and Ohio State doctoral student Basant Abdulrahman showed that macrophages isolated from both mice and humans that carried the most common CF mutation could not clear the B. cenocepacia infection. The bacterium invades the macrophage and just sits there, Amer explained, instead of being digested and cleared away.

Because autophagy was not working in these cells, the researchers tested the effects of the drug rapamycin, an immune-system suppressant that is known to stimulate autophagy, in normal animals and those with the most common CF genetic mutation.

The drug had no real effect on normal mice because they could clear a B. cenocepacia infection on their own, said Abdulrahman, the study's lead author and presenter of the research at Experimental Biology 2012. But in mice with CF, she said, the drug's stimulation of the autophagy process helped these mice clear the bacterial infection from their lungs.

With this strong suggestion that autophagy is a potential target for new CF treatments, the researchers set out to better understand this process in CF macrophages that are unable to fight the B. cenocepacia infection. And that is when they found that p62 shows promise as an even more specific drug target. Additional studies of p62's effects on this bacterial infection are in progress.

Cystic Fibrosis Drug Bronchitol Approved, EU

According to Pharmaxis, Bronchitol, a new cystic fibrosis treatment, has been granted EU approval for patients aged 18 years and older as an add-on therapy to the best standard of care in 29 European countries.

Dr. Alan Robertson, CEO of Pharmaxis announced:

"This is a very significant event, which means that patients living with cystic fibrosis in Europe will now be able to receive the proven clinical benefits of Bronchitol."

The first to benefit from Bronchitol will be CF patients in Germany and the UK, where there is a lower requirement approving prices and reimbursement prior to the drug's launch. Both countries make up 40% of the European market by value. According to Pharmaxis, stock should be available for sale in Europe by June 1st ahead of the product's official launch at the European Cystic Fibrosis Conference in Dublin (6th to 9th June 2012).

Bronchitol has been designed to help clear people's airways who suffer from the world's most common, life-limiting genetic disease - cystic fibrosis. Bronchitol demonstrated in two large Phase III clinical trials that it improved mucus clearance, improved lung function and decreased the number of infectious episodes in comparison to controls after 6 months of therapy. Dr Robertson declared:

"We have built considerable momentum around Bronchitol in recent months with the German and UK sales teams fully recruited and trained. Pharmaxis has now secured three drug approvals in the world's largest pharmaceutical markets: the lung function test Aridol in Europe and the US and now approval for Bronchitol in Europe and Australia. This is a credit not only to the company but also the investigators and patients throughout the world who have taken part in our clinical programs."

Airways More Acidic In Cystic Fibrosis Patients, Less Effective At Killing Bacteria

The human airway is a pretty inhospitable place for microbes. There are numerous immune defense mechanisms poised to kill or remove inhaled bacteria before they can cause problems. But cystic fibrosis (CF) disrupts these defenses, leaving patients particularly susceptible to airway infection, which is the major cause of disease and death in CF.

Using a unique animal model of CF, a team of scientists from the University of Iowa has discovered a surprising difference between healthy airways and airways affected by CF that leads to reduced bacterial killing in CF airways. The finding directly links the genetic cause of CF - mutations in a channel protein called cystic fibrosis transmembrane conductance regulator (CFTR) - to the disruption of a biological mechanism that protects lungs from bacterial infection.

The study, published in Nature, shows that the thin layer of liquid coating the airways is more acidic in newborn pigs with CF than in healthy newborn pigs, and that the increased acidity (lower pH) reduces the ability of the liquid to kill bacteria. Moreover, making the airway liquid less acidic with a simple solution of baking soda restores bacterial killing in CF airways to almost normal levels.

Although the findings suggest that therapies that raise the pH of the airway surface liquid (ASL) may help prevent infection in CF, the researchers strongly caution that this discovery is at an early stage.

"Some have asked us if people with CF should inhale an aerosol that would raise the pH of the ASL," says Joseph Zabner, M.D., UI professor of internal medicine and senior study author. "At this point, we have no idea if that would help. And more importantly, it could be harmful."

"This was a very surprising finding," adds Alejandro Pezzulo, M.D., UI postdoctoral fellow and co-lead author of the study. "There have been many ideas as to what goes wrong in CF, but lack of a good experimental model has made it difficult to gain insight into how the disease gets started."

Unlike mouse models of the disease, the CF pigs develop lung disease that closely mimics what is seen in humans. Previous studies from the UI lab showed that although the airways of CF pigs are infection-free at birth, they are less able to get rid of bacteria than healthy airways and quickly become infected.

Testing bacterial killing in airways

The UI team, including Pezzulo and co-lead author Xiao Xiao Tang, Ph.D., a Howard Hughes Medical Institute postdoctoral research associate at the UI, developed a simple experiment to study bacterial killing by the ASL. They immobilized bacteria on a tiny gold grid and exposed these bacteria to ASL from CF-affected and healthy pigs.

The ASL from normal airways killed most of the bacteria very rapidly, whereas the ASL from CF-affected airways only killed about half of the bacteria, suggesting that in CF airways some bacteria would survive and go on to cause infection.

Further investigation showed that although many characteristics of the ASL in CF and non-CF pigs are similar, the ASL from CF airways is more acidic than the liquid from healthy airways.

When the scientists raised the pH of the ASL in CF pigs through inhalation of a solution of sodium bicarbonate (baking soda), the treated ASL was capable of killing most of the bacteria on the grid (just like ASL from normal airways). Conversely, lowering the pH of ASL from normal airways reduced bacterial killing. The finding confirms that pH is a critical factor for bacterial killing,

"This study explains why a defect in the CFTR channel protein leads to reduced bacterial killing and an airway host defense defect," Tang says. "Impaired bicarbonate transport because of the defective CFTR could cause increased acidity in the ASL, which the study shows reduces the ASL bacterial killing capability."

Potential clinical applications

Although the approach is not ready for clinical application, the study indicates that pH is a contributing factor in airway infection, suggesting that therapies that modify airway pH may potentially be helpful in preventing infection in CF patients.

In addition, the researchers believe that using the bacteria-coated grids to measure bacterial killing in airways might provide a simple way to test the effectiveness of other new CF therapies that currently are being developed.

DNA From Cystic Fibrosis Patients With And Without Chronic Infections Points To Unsuspected Mutation

Comparing the DNA from patients at the best and worst extremes of a health condition can reveal genes for resistance and susceptibly. This approach discovered rare variations in the DCTN4 gene among cystic fibrosis patients most prone to early, chronic airway infections.

The DCTN4 gene codes for dynactin 4. This protein is a component of a molecular motor that moves trouble-making microbes along a cellular conveyer belt into miniscule chemical vats, called lysosomes, for annihilation.

This study, led by the University of Washington, is part of the National Heart Lung and Blood Institute GO Exome Sequencing Project and its Lung GO, both major National Institutes of Health chronic disease research efforts.

Similar "testing the extremes" strategies may have important applications in uncovering genetic factors behind other more common, traits, such as healthy and unhealthy hearts.

The results of the cystic fibrosis infection susceptibility study appear in Nature Genetics.

The infection in question was Pseudomonas aeruginosa, an opportunistic soil bacterium that commonly infects the lungs of people with cystic fibrosis and other airway-clogging disorders. The bacteria can unite into a slithery, hard-to-treat biofilm that hampers breathing and harms lung tissue. Chronic infections are linked to poor lung function and shorter lives among cystic fibrosis patients. These bacteria rarely attack people with normal lungs and well-functioning immune systems.

In the study, these rare variations in DCTN4 did not appear in any of the cystic fibrosis patients who were the most resistant to Pseudomonas infection. The study subjects most susceptible to early, chronic infection had at least one DCTN4 missense variant. A missense variant produces a protein that likely can't function properly.

The lead author of the report published July 8 in Nature Genetics is Mary J. Emond, research associate professor of biostatistics at the University of Washington School of Public Health in Seattle. The senior author is medical geneticist Michael Bamshad, UW professor of pediatrics in the Division of Genetic Medicine.

To the extent of their knowledge, the researchers think that this might be the first time that genetic variants underlying complex trait were discovered by sequencing all the protein-coding portions of the genomes of people at each extreme of a disease spectrum.

"We did not have a candidate gene in mind when we did this study," said Emond. Statistical analysis of the DNA of 91 patients led the research team to this particular gene. Of the initial study group, 43 children had their first onset of chronic lung infection with Pseudomonas as when they were very young, and the 48 oldest individuals had not yet reached a state of chronic infection. The patients selected for sequencing were from the Early Pseudomonas Control (EPIC) Observational Study, a project at the Seattle Children's Research Institute, and the North American Cystic Fibrosis Genetic Modifiers Study. Exome sequencing was done by UW researchers in the laboratory of Deborah Nickerson, UW professor of genome sciences.

Comparisons of the protein coding portions of the study subjects' DNA called the researchers attention to missense variations of the DCTN4 gene. The researchers went on to screen a selected group of 1,322 other EPIC participants to check their findings.

Exome Sequencing Project scientists are using an approach similar to the one in this study to examine the genetics behind resistance and susceptibility to other chronic conditions like obesity, heart attacks and hypertension. They plumb for gene variations linked to heart disease, for example by putting DNA maps from people with ideal cholesterol levels up against those from people with exceptionally poor levels.

Adapting a similar strategy to determine the genetics underlying other complex human traits may require exome sequencing of a much larger sample sizes, the researchers noted.

"As the costs of exome sequencing are dropping rapidly and more efficient statistical analysis is becoming available, we think medical researchers' enthusiasm for this approach will continue," Bamshad predicted.

A New Way Of Clearing The Air For People With Cystic Fibrosis And COPD

University of North Carolina scientists have uncovered a new strategy that may one day help people with cystic fibrosis and chronic obstructive pulmonary disorder better clear the thick and sticky mucus that clogs their lungs and leads to life-threatening infections. In a new report appearing online in The FASEB Journal, researchers show that the "SPLUNC1" protein and its derivative peptides may be able to help thin this thick mucus by affecting the epithelial sodium channel (ENaC). Not only does this research have implications for cystic fibrosis and COPD, but it also enhances the understanding of hypertension due to the role it also plays in controlling blood pressure.

"We hope that this study will pave the way for a new class of peptide-based channel inhibitors that can help reverse the mucus dehydration seen in Cystic Fibrosis and COPD," said Robert Tarran, Ph.D., a researcher involved in the work from the Cystic Fibrosis/Pulmonary Research and Treatment Center at the University of North Carolina in Chapel Hill. "This would help restore mucus clearance and kick-start the lung's ability to clear unwanted pathogens."

To identify which part of SPLUNC1 actually affects ENaC, scientists eliminated parts of the protein until it lost function. In fact, even after the eliminating 85 percent of SPLUNC1, it still affected ENaC, suggesting that the ENaC inhibitory domain was in the remaining 15 percent. Researchers then synthesized an 18-amino acid peptide of this region and tested its ability to bind to ENaC and to inhibit fluid absorption in human bronchial epithelial cells derived from people with and without cystic fibrosis. This peptide inhibited ENaC and fluid absorption in all systems tested, without affecting structurally-related ion channels. They also found that ENaC activity was affected for more than 24 hours in cystic fibrosis airway cultures, suggesting that this peptide may be therapeutically beneficial for the treatment of cystic fibrosis patients who suffer from over-active ENaC and consequentially have too little lung fluid.

"Breathing is something most healthy people take for granted." said Gerald Weissmann, M.D., Editor-in-Chief of The FASEB Journal. "However, people with cystic fibrosis and COPD battle for every breath because sticky mucus plugs their airways. This research should give scientists a new way of clearing the air for people with cystic fibrosis and COPD."

Kalydeco Recommended For Treatment Of Cystic Fibrosis

About 60,000 Europeans suffer from cystic fibrosis, a rare and life-threatening genetic disorder that is caused by a mutation of the CFTR gene, which regulates salt and water transport in the body. The CFTR mutation in cystic fibrosis patients allows too much salt and water into cells, which results in a build-up of thick, sticky mucus in the body's tubes and passageways that damage the lungs, digestive system and other organs. Symptoms generally occur during early childhood and appear as persistent cough, recurring chest and lung infections and poor weight gain.

The European Medicines Agency (EMA) has recommended an orphan-designated medicine called Kalydeco (ivacaftor) to treat cystic fibrosis in children above the age of 6 years who have a G551D mutation in the cystic fibrosis transmembrane regulator (CFTR) gene. Kalydeco was reviewed in only 150 days by the Committee for Medicinal Products for Human Use (CHMP), under EMAs accelerated assessment procedure, which speeds up the reviewing process to supply patients with new drugs that are of major public health interest.

Unlike currently available therapies, which only address the disease's consequences, Kalydeco is the first treatment that targets the underlying mechanism of cystic fibrosis by restoring the function of the mutated CFTR protein, therefore providing patients with an innovative therapeutic approach.

Kalydeco demonstrated improved pulmonary function in cystic fibrosis patients with the specific G551D-CFTR mutation in clinical studies. The drug's most frequently encountered side effects included abdominal pain, diarrhea, dizziness, rash, upper respiratory tract reactions, including upper respiratory tract infection, nasal congestion, pharyngeal erythema, oropharyngeal pain, rhinitis, sinus congestion and nasopharyngitis, as well as headache and bacteria in sputum. Long-term safety data for Kalydeco is so far unavailable and will therefore, like all newly approved medicines be closely monitored.

So far, three of the eight medicines that have been approved under The Agency's accelerated assessment have been orphan-designated medicines. The Agency is currently waiting for the E.C. to adopt the decision of their recommendations.