Cystic fibrosis organisations, rare paradigms of good clinical care and the increasing use of the sweat test
During the Sixties more national CF organisations were formed, usually following pressure from parents and engendering a collaborative approach between the medical community and the CF families; but few people other than those closely involved had even heard of cystic fibrosis. The US National CF Research Foundation (later the CF Foundation) had been formed in 1955 (above), and the Canadian CF Foundation in 1959 (above). Subsequently, national CF organisations formed in many countries where CF was identified; their programmes covered welfare, support, advocacy, clinical care, professional education and research, depending on the local stage of development.
In 1964 the UK “Cystic Fibrosis Research Foundation Trust” was formed as a charitable organisation to raise funds for research. Later, as more patients survived and an increasing proportion of the research funds went to support clinical care in the developing CF centres during the Eighties, the scientists on the Research and Medical Advisory Committee of the UK CF Research Trust requested the title of the organisation be amended to the “The Cystic Fibrosis Trust” as an increasing proportion of funding was going to patient care rather than research! Many years later, in the late Nineties, the CF clinicians, many with large CF clinics, complained bitterly that too great a proportion of the CF Trust’s resources was going to the scientists working on gene replacement therapy!
In 1965 the International Cystic Fibrosis (Mucoviscidosis) Association (ICFMA), the predecessor of CF Worldwide, was formed in Paris under the medical chairmanship of Paul di Sant’Agnese. In 1960, prior to his moving from New York to The National Institutes of Health, di Sant’Agnese visited Europe to meet other clinicians interested in cystic fibrosis. These included Prof. Guido Fanconi and Prof. Ettore Rossi (Switzerland), Prof. Andre Hennequet and Dr Jean Feigelson (France), Drs Archie Norman and David Lawson (England), Prof. G de Toni (Italy) and Profs. Weijers, Dicke and Van de Kamer (Holland). The aims of the ICFMA were to improve the care of children and adults who had CF, to foster research and to disseminate information. Also di Sant’Agnese notes that prior to this meeting those working in CF did not know each other except through the literature and so the ICFMA brought together physicians, paramedical personnel and lay people giving them a sense of common purpose. This was the start of the International CF (ICFMA) now CF Worldwide meetings, which occur every 4 years. It is difficult to appreciate the problems with communication and travel in the Sixties - before the days of easy air travel, photocopiers, fax machines, e-mails, internet and medical databases such as Medline and PubMed.
In 1969, the European Working Group for Cystic Fibrosis (EWGCF) was formed to provide an annual forum where people from the various disciplines, but with a common interest in CF, could meet, present and discuss their latest findings. Since 1970, there has been an annual meeting (except every four years when there is a combined meeting of the International Cystic Fibrosis Congress) in a different European country and organised in conjunction with the local CF association. In 1997, following suggestions over a number of years by the membership, the Board decided to propose an official transformation of the EWGCF to a Society to be known as the European Society for Cystic Fibrosis (ESCF). However, subsequently it was realised that the name abbreviation was similar to that of a study group associated with the American CF Foundation (Study of Epidemiology of Cystic Fibrosis). Consequently the name of the European society was changed again at the Annual General Meeting held at the 22nd European CF Conference in Berlin, June 1998 to the European Cystic Fibrosis Society (ECFS). An account of the history of the ECFS, based on presentation given by Niels Hoiby at the annual ECFS Conference in 2007, is in the "Some previous publications on the history of cystic fibrosis" in the Future section.
During the Sixties sweat tests gradually became more widely available following the publication of the pilocarpine iontophoresis method of sweat stimulation by Gibson and Cooke (1959, above). I was impressed by Dr Tom McKendrick’s sweat test study (McKendrick, 1962 below) in progress when I was a house physician at the Hospital for Sick Children, Great Ormond Street in London. So on returning to Leeds, as a Lecturer in Paediatrics, I arranged for the purchase of a sweat-testing box and our biochemist, Mr Alan Steele, soon introduced accurate sweat tests. By 1968, with our recently introduced paediatric jejunal biopsy service to identify coeliac disease, most infants and children with malabsorption problems could be accurately diagnosed. Both these services were used by many paediatricians in the Yorkshire region (population 3.6 million) and the seeds of the Leeds Regional CF Service were sown.
Paul Quinton notes that CF research in the Fifties, Sixties and Seventies, searching for the basic defect that would unify the disparate symptoms of the disease, followed numerous paths mainly based primarily on empirical observations, often completely unrelated to any known pathology – the era he described as the “Wild West” era of research (Quinton, 1999 below). So essentially during the Sixties there was little progress in the understanding of the basic defect in cystic fibrosis.
|Fig.1: Sir Robert Johnson in 2005|
Although by no means the first to perform stimulated pancreatic function tests on children with CF, the name of Beat Hadorn is closely associated with accurate stimulated pancreatic function tests in CF; he described the pancreozymin–secretin stimulation test using a triple lumen tube. Hadorn showed that in CF there was a markedly reduced volume of stimulated pancreatic juice and abnormally low bicarbonate levels even in those few people with CF who had sufficient residual pancreatic function to achieve normal fat absorption (Hadorn et al, 1968 below). However, although these tests were useful they were invasive and unpleasant for the children and required significant sedation, duodenal intubation and intravenous access. Later, non-invasive faecal chymotrypsin levels (Barbero et al, 1966 below; Brown et al, 1988 below) and more recently faecal pancreatic elastase 1 measurements have simplified the recognition of pancreatic insufficiency (Wallis et al, 1997 below; Cade et al, 2000 below). So although there had been some progress in a few clinics, particularly with regard to making the diagnosis with the sweat test, the outlook for most children with CF remained very poor with very few even reaching adolescence. Although there were reports of an improving outlook from a few large CF centres, most children in the UK did not attend a CF centre and most still died within the first few years. The nature of the basic defect remained totally obscure; also relatively few scientists were researching the problem.
Sir Robert Johnson (figure 1), a parent of two children with CF, was one of the founders of the UK Cystic Fibrosis Trust in 1964 and until recently a member of the Board and Vice Chairman. He recalls the depressing situation facing CF families in the UK in the Sixties - “the general picture here was of ignorance and distress, unmitigated by hope or practical effective action”. As a young paediatrician in the Sixties I can certainly vouch for the hopeless outlook for infants identified as having CF at that time.
Sixties - Science
Composition and characteristics of the airway secretions and CF factors e.g. the “Spock factor”
Chernick WS, Barbero GJ, Eichel HJ. In vitro evaluation
of the effect of enzymes on tracheobronchial secretions from patients
with cystic fibrosis. Pediatrics 1961; 27:589-596. [PubMed]
Effect of various enzymes on the viscosity of CF sputum showed that pancreatic dornase had the most marked effect showing complete dissolution of the fibrous structure of the sputum. This finding supported the theory that the excessive viscosity of CF sputum (figure 1a) was related to a fibrous network observed in the sputum which was primarily of deoxyribonucleoproteins as had been shown by this group (Chernick et al, 1959 above).
Fig. 1a: Viscid sputum from a person with cystic fibrosis.
The effect of enzymes on the sputum had been reported in other chronic pulmonary conditions (Sherry S et al. Proc Soc Exp Biol Med 1948; 68:179-184.[PubMed]) and also on CF sputum (Shwachman & Leubner, 1955 above). These and other early studies eventually led to the introduction of rhDNase (Pulmozyme) as an effective mucolytic but only after the side effects of the biological product were circumvented by producing the genetically engineered product rhDNase (Pulmozyme) (Shak et al, 1990 [PubMed] below).
Armstrong JB and White JC (Lancet 1950; 2:739. [PubMed] above) had shown that deoxyribonuclease would liquefy viscous purulent exudate; later Elmes PC & Armstrong JB (Thorax 1953; 8:295-300.[PubMed]) reported its use in chronic bronchitis, but the side effects of the bovine preparation precluded its use and further development (Raskin P. Am Rev Respir Dis 1968; 98:697-698. [PubMed]).
Shwachman (1955 above) mentions that May and Lowe used a pancreatic preparation by inhalation in one patient and that at autopsy widespread granulomatous lesions were found in the lung, a lesion not seen in any other patient. However, eventually Shak et al (1990,[PubMed] below) cloned, sequenced, and expressed rhDNase which later became one of the major advances in treatment of the Nineties (Fuchs et al. 1994 below).
Reid L. The composition of tracheobronchial secretions in cystic
fibrosis. Postgrad Med J 1961; 37:599-600. [PubMed]
Professor Lynne Reid (figure 2) was a prominent CF researcher at the Brompton Hospital in London before she moved to the USA. Her first academic appointment was as a research assistant at the Institute of Diseases of the Chest at London University. She was appointed a professor of experimental pathology at London University in 1967, and was made Dean of the Cardiothoracic Institute at London University in 1973. Later in 1976 she accepted a position on the faculty of Harvard Medical School, as one of the school's few women faculty members. Most of her publications concerned the bronchial secretions and the characteristics of bronchial mucous glands. These were popular areas for research for the few researchers involved in CF at the time, so copious and so very viscid was the sputum of people with cystic fibrosis (figure 1a). As it eventually turned out there were no intrinsic structural abnormalities of the mucus. During her time in the UK Lynne reid was a good friend to and closely involved with the UK Cystic Fibrosis Research Trust. She reviewed much of her research in 1981 at the Minnesota Meeting (1000 Years of Cystic Fibrosis. Collected Papers. Warren J Warwick. University of Minnesota, 1981) but she had to conclude that "the reason for the susceptibility of infection still eludes us".
|Fig.2a: Jack Lieberman|
|Fig. 2: Lynne Reid. From www.nlm.nih.gov/ changingthefaceofmedicine.|
|Fig. 3: Aaron Holzel.|
|Fig. 4: Giulio Barbero|
Lieberman J. Enzymatic dissolution of pulmonary secretions. An in
vitro study of sputum from patients with cystic fibrosis of the
pancreas. Am J Dis Child 1962; 104: 342-348.[PubMed]
Dr Jack Lieberman of Los Angeles observed that a favourable effect on sputum viscosity by the addition of enzymes had been reported both in vitro (Chernick et al, Pediatrics 1961; 27:589 above) and in vivo (Shwachman et al. Pediatrics 1960; 25:155). This present study confirmed the liquefaction which occurred in the presence of various enzymes in order of effect – trypsin, ficin, chymotrypsin, deoxyribonuclease and elastase.
There was an interesting editorial comment to this article as follows – “Now if someone can find a way to bring a sufficient quantity of a non-irritating mixture of enzymes to bear on the bronchiolar mucus he can see if it works in the patient”. This did eventually occur with rhDNase (Pulmozyme) but it was to be some 30 years before this was achieved (Shack et al. 1990; Fuchs et al, 1994 both below). (Also Lieberman J. JAMA 1968; 205:312-313 below).
Dr Jack Lieberman (1926-2011) (figure 2a) received his B.S. from UCLA and his M.D. from the University of Southern California in 1954. He spent many years working for the V.A. Hospital and doing research on Cystic Fibrosis. He was a Professor Emeritus for the UCLA School of Medicine and Chief of Respiratory Disease at the Sepulveda V.A.
Chernick WS, Barbero GJ, Parkins FM. Studies on submaxillary saliva
in cystic fibrosis. J Pediatr 1961; 59:890-898.[PubMed]
Chernick published a number of papers on the function of the salivary glands. The submaxillary saliva in CF was abnormal. Normally clear in non-CF people, the secretion in those with CF was turbid and the levels of calcium, protein and glycoproteins were increased. After injection of guanethidine the turbidity cleared and, with the exception of calcium, the increased levels of the other constituents were reversed.
Holzel A, Schwarz V, Torkington P, Greville Williams GE. Mucoviscidosis
and the autonomic nervous system. Lancet 1962; 1:822-823. [PubMed]
Dr Aaron Holzel (figure 3) was a paediatrician working in the University of Manchester, England. He published on a wide variety of paediatric subjects including CF and started the first CF clinic in Manchester. He was also involved in early meetings concerning cystic fibrosis.
Subsequent publications by other authors also described possible abnormalities of the autonomic nervous system (Davis PB et al. Pediatr Res 1978; 12:703-707; Davis PB, Kaliner M. J Chron Dis 1983; 36:269-278; Mirakhur A, Walshaw MJ. J R Soc Med 2003; 96 (Suppl.43):11-17.). However, no significant abnormalities were discovered in this area which led to further understanding of the basic defect or to any form of treatment.
Denton R. The rheology of human mucus. Ann N Y Acad Sci 1963; 106:746-754.[PubMed]
This is a relevant paper as the work of Robert Denton was important in the introduction of the mist tent (see Denton 1955 above). The paper concludes with the observation that the degree of flow resistance will show as quantitatively the degree of abnormality and may provide information which can lead to further understanding of the chemical changes within the mucus blanket which are responsible for impaired bronchial drainage.
Chernick WS, Barbero GJ. Studies on human tracheobronchial and submaxillary
secretions in normal and pathophysiological conditions. Ann N Y
Acad Sc 1963; 106:698-708. [PubMed]
The authors state - “Data relating to the tracheobronchial secretions and submaxillary saliva in cystic fibrosis indicate the high concentrations of various organic constituents which are secreted in this disease and the possible interrelationships of electrolytes on the physical properties of such constituents”.
So, as with most of these studies on the physico-chemical characteristics of the airway secretions, unfortunately there were no firm conclusions which significantly advanced understanding of the basic defect of the condition. It is interesting that these authors again mentioned the possible role of the electrolyte content of the sputum which eventually turned out to be very relevant.
Professor Giulio Barbero (1923-1997) (figure 4) was internationally recognised for his research in CF and patient advocacy. He published extensively on CF and general paediatric topics from 1953 to 2001. He was Head of Pediatrics at the University of Missouri, Columbia from 1972-1989. He gave the third Joseph Levy Memorial Lecture at the European CF Meeting in Jerusalem in 1996 entitled "The Science and Humanity of Cystic fibrosis".
Kwart H, Mosley WW Jr, Katz M. The chemical characterization of
human tracheobronchial secretion: a possible clue to the origin
of fibrocystic mucus. Ann N Y Acad Sci 1963; 106:709-21. [PubMed]
One of many studies that attempted to show differences between normal and CF mucus. The authors suggest their findings appear to support the basis for the disease they had advanced earlier i.e. that the extraordinary viscidity of CF mucus was formed as a result of a defect in “membrane chemistry”. They consider that the inference is consistent with the difficulties that CF individuals experience conserving sodium chloride.
So another group whose conclusions were not too far off the mark as it turned out. However, in contrast to the excessive loss of salt via the sweat, people with CF had a deficiency of salt in the airway secretions due to the excessive absorption of sodium and reduced passage of chloride into the airways.
Matthews LW, Spector S, Lemm J, Potter JL. Studies on pulmonary
secretions I. The over-all chemical composition of pulmonary secretions
from patients with Cystic Fibrosis, Bronchiectasis and Laryngectomy.
Am Rev Resp Dis 1963; 88:199-204. [PubMed]
Leroy Matthews was one of the leading clinical authorities on CF in the USA at the time. He was developing his Comprehensive Treatment Programme in Cleveland which was to become the model for CF care adopted by the CF Foundation for their Centres programme. In this study they found that total solids, DNA protein, lipid and carbohydrate were highest in CF secretions, intermediate in non-CF bronchiectasis and lowest in normals.
The marked decrease in sodium and chloride in CF sputum which they found they considered was possibly related to the infection – “if this is so it makes untenable the hypothesis that the lowered sodium and chloride content of the cystic fibrosis secretions is etiologically responsible for the disease”.
This is interesting for later the “low salt theory” was to be regarded as the most likely explanation for the alteration in the pulmonary secretions and the persisting pulmonary infection problems.
1964 Freye HB, Kurtz SM, Spock A, Capp MP. Light and electron
microscopic examination of the small bowel of children with cystic
fibrosis. J Pediatr 1964; 64:575-579. [PubMed]
Twenty one duodenal/jejunal mucosal biopsies were obtained from children with CF and showed normal villi and cell structure but the surfaces were covered by “a coarse fibrillar substance probably mucus” in those children who had steatorrhoea but not from the one patient that had normal fat absorption. The findings were considered to support the concept of Dische that mucus may contribute to the absorptive defect (Dische Z et al. Pediatrics 1959; 24:74-91. [PubMed]).
These were early days for per oral jejunal biopsy in children and this was the first large study in children with cystic fibrosis. Earlier di Sant’Agnese had observed that “the histological picture on per oral biopsy is apparently normal as might be expected” (di Sant’Agnese et al. Rev Nutr Res 1961; 22:29-50). However, the present findings did not carry matters forward a great deal.
My impression was that the intestinal villi were unusually tall in the few children with CF whom we biopsied to exclude coeliac disease.
Reid L, De Haller R. The bronchial mucous glands – their hypertrophy
and change in intracellular mucus. Mod Prob Pediatr 1967; 10:195-199. [PubMed]
Lynne Reid was a prominent UK researcher (Reid, 1961 details above). In 1981 she reviewed her work over the decade at the Minnesota CF meeting (Bronchial mucus and its glycoproteins in cystic fibrosis. In: Warwick WJ (Ed.). 1000 Years of Cystic Fibrosis - Collected papers. University of Minnesota. 1981:179-184).
Although a great deal of work was carried out on the various physico-chemical properties of mucus, none appears to have had a significant effect on either the treatment or the further understanding of the basic defect – except perhaps that the increased viscosity was due to the high DNA content which was eventually improved by the use of genetically engineered rhDNase (Pulmozyme) (Shak et al, 1990 below; Fuchs et al, 1994 below).
Spock A, Heick HM, Cress H, Logan WS. Abnormal serum factor in patients
with cystic fibrosis. Pediatr Res 1967; 1:173-177. [PubMed]
In the course of research into the effects of tobacco on the action of cilia, Dr Alexander Spock of Duke University discovered a “factor” in the serum from CF patients, which inhibited cilia beating in explants of rabbit trachea. It was reported the “factor” would cause increased mucus release as well as causing marked slowing of ciliary beating. It was present in all of 75 people with CF but not in 75 controls.
The finding received much attention around this time and was thought to be related in some way to the basic defect - perhaps abnormalities were mediated via a CF ‘anti-ciliary’ factor in the serum found to be associated with the IgG containing fractions (Bowman et al, Science 1969; 164:325-6).
Besley et al,
1969 (below) found the effect also with the gills of the freshwater
mussel Dreissenia Polymorpha. Bowman et al reported the
effect also occurred in oyster gill cilia (Science 1969; 164:325-6)
and the effect could be reversed by heparin – the factor responsible
being a cationically charged protein (Doggett RG, Harrison GM. Tex
Rep Biol Med 1973; 31:685-689).
Spock’s report caused a great deal of interest – but in all fairness, the observations did little to advance the understanding of the basic defect or treatment of cystic fibrosis.
Dr Akexander Spock (1929-2014) (figure 4a) was Chief of the Pediatric Pulmonary and Gastroenterology
Division at Duke University. He was the founder of the Duke Cystic Fibrosis Center and directed the center, one of the largest in the Southeast, between 1962-1990. Although limited by a physical disability since 1990, he remained active as a mentor, consultant, and publisher. He authored or co-authored over 190 scientific publications during his career - between 1959 and 2005.
|Fig.4a: Alexander Spock|
|Fig. 4a: John Mangos. From www.pediatrics.uthscsa.edu|
Mangos JA, McSherry NR. Sodium transport inhibitory factor in sweat
of patients with cystic fibrosis. Science 1967; 158; 135-6. [PubMed]
John Mangos (figure 4a) was a leading CF researcher at this time. A factor that inhibited sodium transport was detected in the sweat of patients with cystic fibrosis. When the duct system of the rat parotid was perfused with sweat from patients with CF, marked inhibition of sodium reabsorption was observed. Perfusion with sweat from normal subjects caused no change in sodium reabsorption. The authors suggested that the factor may be responsible for the increased sodium concentrations in the sweat of patients with cystic fibrosis (Also Pediatr Res 1967; 1:436; Pediatr Res 1968; 2:378).
Danes BS, Bearn AG. A genetic cell marker in cystic fibrosis of
the pancreas. Lancet 1968; i: 1061- 1063. [PubMed]
Fibroblasts from many but not all patients with CF, when stained with toluidine blue, showed intracellular metachromasia. The findings depended on many factors and later there was a more detailed report by same authors (J Exp Med 1969; 129:775-793.). However, eventually no significant difference was shown between CF and normal fibroblasts (Spicer et al, 1980 Exp Mol Path 33:104).
Kilburn KH. A hypothesis for pulmonary clearance and its implications.
Am Rev Respir Dis 1968; 98:449-463. [PubMed]
Kilburn deduced that deep in the airways there is a tremendous amount of mucus formed probably several litres per day. But by the time the mucus reaches the trachea it has been reduced to a very small amount. So something must be happening in the small airways to absorb the bulk of this liquid.
Prof. John Widdicombe considers this paper stimulated subsequent research and interest into how the respiratory epithelium transports water and sodium chloride.
Besley GT, Patrick AD, Norman AP. Inhibition of motility of gill
cilia of Dreissensia by plasma of cystic fibrosis patients and their
parents. J Med Genet 1969; 6:278-80. [PubMed]
Ciliary dyskinesia factor was assayed in fresh water mussel cilia (Dreissensia Polymorpha), which proved to the most satisfactory alternative for cilia inhibition tests.
Crawfurd M d’A. Experience of the cilia test for a factor
in the serum of patients and carriers of cystic fibrosis. Proc.
5th International CF Conference, Cambridge Sept 1969. 42- 48.
There was great interest in the “CF factor” and Dr Martin Crawfurd, working in Leeds, studied our patients using the cilia of fresh water mussels. He obtained positive results on 11 of 12 patients with CF, 150 of 163 parents, 28 of 47 siblings and 15 of 162 controls.
Although this test was eventually abandoned, on one occasion a positive ‘cilia test’ performed by Martin Crawfurd, caused us to persevere with establishing the diagnosis of CF in a girl aged one year whom we initially thought had Shwachman–Diamond syndrome. She had severe fat malabsorption from early infancy and the jejunal biopsy showed an entirely normal intestinal mucosal histology but the sweat tests, performed by the experienced staff at a reliable laboratory, were repeatedly normal. However, the child eventually developed an abnormal sweat test and the typical clinical features of CF; she eventually died at the age of 25 years from her pulmonary disease caused by the chronic Pseudomonas infection.