Health Column

The questions and answers in this column were taken from past issues of the SVB newsletter. All the information in this section is periodically checked and brought up to date by Dr. Michel Ruel of the Centre hospitalier universitaire de Québec (CHUQ), CHUL Pavilion.

The importance of this column lies in the fact that it provides answers to questions most frequently asked by CF patients to physicians who are specialized in cystic fibrosis. By clicking on a topic, you will access the questions and answers related to the chosen theme.

SYMPTOMS

Acute Sinusitis
Anemia and cystic fibrosis
Arteriosclerosis and heart disease
Arrhythmia and tachycardia
Bad breath
Clubbing
CO2 and Oxygen Flow
Delayed growth
Diabetes and cystic fibrosis
Enlarged heart and cystic fibrosis
Fever
Gastroesophageal reflux
Hemoptysis
Laryngitis
Pancreatic cystic fibrosis
Pneumothorax (respiratory system)
Thirst

TREATMENT

Antibiotics

Antibiotics, intestinal flora and probiotics
Antibiotics and Length of Treatment
Antibiotics: Milk and Alcohol
Antibiotics: Vitamins
Cipro® and Fitness Training
Photosensitivity and Intravenous Antibiotics
Tobi®

Catheters long catheter
Catheters P.A.S. Port and Port-A-Cath
Corticosteroids (cortisone): Action and Side Effects
Cortisol
Cough Syrup
Cyclosporine: Action and Side Effects
Desensitization
Ibuprofen
Ibuprofen and Scarring
Methadone
Monoclonal Antibodies
Omega-3
Oxygen Therapy
Pancreatic enzymes
Super anti-inflammatory drugs (Vioxx^TM, Celebrex^TM and Bextra^TM)
Tamiflu®
Ventolin® Storage
Vitamin E and Cystic Fibrosis
Weight and Force Feeding

TRANSPLANTATION

Blood types
Grapefruit
Pregnancy and Lung Transplantation
Transplantation: Pancreatic Transplantation
Transplantation and Kidney Problems

SEXUALITY

Exercise
Semen
Vaginitis
Viagra^TM

MOTHERHOOD, FATHERHOOD

Male Infertility
Mild Form of CF and Male Fertility

COMMUNITY LIFE

Contamination Risks

GENERAL

Acne and Accutane^TM
Anti-Viral Vaccines
Arterial Blood Gas
Cystic Fibrosis and Blood Donations
Candida albicans
Childhood diseases (smallpox, measles, German measles, mumps, etc.)
Clostridium difficile
Donor Virus
Ecstasy
Flu Vaccine
Hair removal
Indoor Plants
MRSA
Multiresistant Pseudomonas
Pneumococcal Vaccination
Research Phases
Sports to Avoid
Terminology
Vaccines and travel

Omega-3

Lately, I have been hearing a lot about the benefits of food high in omega-3 fatty acids. What are these exactly? What led to the sudden discovery of their benefits? Is food high in omega-3 good for people with cystic fibrosis?

Omega-3 fatty acids are long-chain polyunsaturated fatty acids. They are mostly found in fish and fish oil, but they can also be taken in concentrated form in capsules. This type of fatty acid is primarily valued for its role in protecting the cardiovascular system. It was observed that there were few cases of cardiovascular disease among the Inuit of Greenland, despite levels of bad cholesterol similar to those in the Danish population, which is more affected by this type of disease. The difference is believed to be attributable to the greater amount of fish, and consequently, omega-3, in the Inuit diet. The cardio-protective mechanisms involved include a reduction in triglycerides combined with an increase in good cholesterol, protection against the formation of blood clots in the blood vessels and direct inhibition of inflammation of the blood vessels which promotes arteriosclerosis (hardening of the arteries). Cardiovascular disease is not usually a problem for persons with cystic fibrosis. However, those who are also diabetic are at risk of developing arteriosclerosis, which is the cause of cardiovascular diseases. Cystic fibrosis patients who have received a transplant could also be at risk of developing arteriosclerosis because of the anti-rejection drugs, some of which promote high blood pressure and diabetes (caused or aggravated by cortisone), which are two conditions that promote arteriosclerosis. Therefore, in these sub-populations, a diet high in omega-3 fatty acids could be beneficial. However, there is no proof to date that the rest of the population would benefit.

HEALTH COLUMN
SVB/ 2005, No 29, page 37

Acne and Accutane^TM

I have what I consider to be a big acne problem. I’m seriously thinking of taking Accutane^TM, even though I have heard some bad things about it. Would you tell me how this drug acts on the body in general and on acne in particular? Could it dry out lung secretions? Do you think there are any risks in taking this drug for someone who has cystic fibrosis?

Accutane^TM (isotretinoin) is a vitamin A derivative. Its mechanism of action in treating acne has not yet been explained. We know, however, that the improvement in the acne is accompanied by a reduction in the secretion of sebum, which depends on the dose or duration of the treatment and indicates a shrinking of the sebaceous glands (that secrete sebum). This drug is known for drying out the skin, nasal membranes and pharyngeal glands. It may also dry out the bronchial glands, although this has not been widely reported. Accutane^TM has been associated with rare cases of bronchospasm, but it is not contraindicated in persons with cystic fibrosis. Because of the undesirable side effects, however, including a potential imbalance in blood fat and blood sugar levels, and a teratogenic effect (causing congenital defects in the embryo), it is only used to treat serious acne that does not respond to conventional front-line therapy. Women who take this drug should avoid getting pregnant during treatment.

HEALTH COLUMN
SVB/ 2005, No 28, page 44

MRSA

I just found out that I am infected with methicillin-resistant Staphylococcus aureus (MRSA). My husband seems more troubled by this news than I am. He is afraid to catch it eventually and suffer the consequences. Can you help us better understand what MRSA is and explain how dangerous it is for sick and healthy people alike?

Over the last few years, there have been an increasing number of antibiotic-resistant bacteria. This is the case with Golden Staphylococcus (Staphylococcus aureus), some of the strains of which have become resistant to methicillin, an antibiotic that closely resembles cloxacillin. MRSA (methicillin-resistant Staphylococcus aureus) first invaded Montreal hospitals, gradually spread to the other hospitals in Quebec, and is now proliferating outside hospitals. This bacterium is neither virulent nor aggressive in healthy people. They may become carriers (usually through the nasal glands) if they have come into contact with patients infected by the bacteria, but they do not get sick and the condition is not necessarily permanent. The situation is different for sick persons who have recently had surgery, however, if their wound becomes contaminated with MRSA. The resulting infection is more difficult to eliminate because of its resistance to conventional antibiotics. The wound will still heal, however, if the patient is treated with antibiotics that are effective against MRSA.

In the cystic fibrosis population, it is difficult to judge the significance of MRSA bronchial colonization. Some patients are only temporarily infected, while others seem to have a chronic infection. It is not yet clear whether MRSA is more virulent and aggressive than methicillin-sensitive Staphylococcus aureus. However, when there is a co-infection of MRSA-Pseudomonas aeruginosa or MRSA- Burkholderia cepacia, in both cases, it appears to be the second bacteria, not MRSA, that are the major cause of morbidity.

HEALTH COLUMN
SVB/ 2005, No 28, page 44

Pneumococcal vaccination

Last fall, I asked my physician for a pneumococcal vaccination. For reasons that were not clear to me, he indicated that this vaccine was not appropriate for persons with cystic fibrosis. Can you explain why? Who is the vaccine for?

This vaccine is effective in significantly reducing the incidence of pneumonia and other infections caused by pneumococcus, the bacterium responsible for the vast majority of pneumonia cases in the general population. In adults with cystic fibrosis, however, the bronchi are chronically infected—in 70% of cases—with Pseudomonas aeruginosa. Pneumococcus is rarely the cause of pneumonia in this population. I recommend the pneumonia vaccine for adults with cystic fibrosis who have only minor lung involvement and are not infected with Pseudomonas aeruginosa. It rarely causes undesirable side effects and is estimated to be effective for seven years, unlike the flue vaccine, which has to be administered annually.

HEALTH COLUMN
SVB/ 2005, No 28, page 45

”Donnor Virus”

I have just had a lung transplant. I’m in great shape and plan to stay that way. At the clinic, I often hear about the ”donor virus,” and would like to know more about it. Where does it come from? Is it contagious? What are the symptoms? How can it be eradicated?

Many viruses can be transmitted through lung and other transplants. In theory, donors could transmit HIV (AIDS virus) and hepatitis B and C viruses to receivers, but in practice, we check to make sure the donors are not carriers (if they are, their organ donation is contraindicated). The virus to which you refer is probably the cytomegalovirus, which is a contagious virus that a large part of the population may contract at some point in their lives. Most of the time, the initial infection is not too severe and may resemble mononucleosis. The symptoms may recede fairly quickly, but a small quantity of the virus may remain in the body; it is kept under control by the immune system and does not cause any problems. However, in the case of transplantation, it can be transmitted to the receivers, especially if they have never been infected by this virus. Receivers are vulnerable to the cytomegalovirus because their defences are weakened by the immunosuppressants they take to avoid rejecting transplanted organs. Symptoms of infection include fever, pneumonia or hepatitis. Antiviral antibiotics are available to prevent or at least to control the infection.

HEALTH COLUMN
SVB/ 2005, No 29, page 36

Clostridium difficile

Over the past few months, there has been considerable talk in the media about Clostridium difficile. I understand that this bacterium is dangerous and very prevalent in Quebec hospitals. How does it differ from other bacteria? Why is everyone talking about it so much? Should the cystic fibrosis population be particularly concerned? How can we reduce the risk of contracting it?

Clostridium difficile, commonly called C difficile, has indeed been in the news a lot lately. Around 1978, it was discovered that C difficile could cause post-treatment diarrhea in patients who had received antibiotic therapy, and it was demonstrated that the toxins produced by this bacterium were linked to intestinal inflammation and diarrhea. This is therefore not a recent problem. However, the increase in the number and severity of these cases is a more recent phenomenon. Clostridium difficile is found in the large intestine of 3 to 5% of the normal population. A previous hypothesis maintained that antibiotic therapy modified the intestinal flora, enabling Clostridium difficile to grow and produce toxins that caused diarrhea, which is a likely cause of colitis contracted outside the hospital. However, the current hypothesis is that people who are hospitalized contract the nosocomial strain, and then following antibiotic therapy in the hospital, this strain, which is potentially more virulent than strains found outside hospitals, produces toxins.

It is quite surprising that colitis caused by Clostridium difficile is not more frequent in persons with cystic fibrosis, because they take an enormous amount of antibiotics. However, this population can contract severe infections, especially when taking antibiotics in the hospital. To prevent these infections, hospital staff have to isolate persons infected with Clostridium difficile and be very careful about washing their hands and wearing gloves and gowns. Moreover, it goes without saying that home-based intravenous antibiotic therapy reduces the risk of unpleasantness caused by Clostridium difficile.

HEALTH COLUMN
SVB/ 2006, No 29, page 37

Multiresistant Pseudomonas

In the hospital where I’m being treated, patients infected with methicillin-resistant Staphylococcus aureus (MRSA) are isolated. Why aren’t patients with multiresistant Pseudomonas isolated too? Since MRSA and multiresistant Pseudomonas don’t respond to antibiotics well, aren’t they both dangerous to other patients?

In all hospitals, patients who are known to carry MRSA are isolated. The main reason for this is that this bacterium is easily transmitted from one person to another, even though it does not produce any symptoms. This bacterium can therefore spread quite insidiously. As its name indicates, methicillin-resistant Staphylococcus aureus is a bacterium that is resistant to antibiotics conventionally used in treating Staphylococcus aureus infections, which makes it hard to treat. A growing number of CF patients have lung infections, which are often chronic, caused by this bacterium. However, it appears to be less virulent than Burlkolderia cepacia and Pseudomonas aeruginosa.

Multiresistant Pseudomonas aeruginosa is also fairly resistant to conventional anti-pseudomonal antibiotics. It is not as contagious as MRSA in the general population, but it is easily transmitted among CF patients, so the purpose of isolation is mainly to protect other CF patients. CF patients who have multiresistant Pseudomonas should obviously not be near patients with reduced immune defences or open wounds. In an ideal world, all hospital rooms would be private, which would simplify isolation techniques. That is already the case in some U.S. hospitals, and it appears that the new CHUM (University of Montreal Hospital Centre) is planning to do this also.

HEALTH COLUMN
SVB/ 2006, No 29, page 37

Candida albicans

I have a Candida albicans infection that seems to be almost cured. Ever since I’ve had this problem, I’ve been worried about being infertile. Is there any way to check whether the fungus has affected my fallopian tubes to the point of making me infertile? How does one contract this type of fungus? Can it affect other organs besides the reproductive organs? What do you think is the best drug for quickly getting rid of this type of infection? And lastly, does this problem tend to recur?

In the gynecological system, Candida albicans affects only the vulva and vagina. This fungus does not affect the uterus, fallopian tubes or ovaries, so there is no danger of becoming infertile following a Candida infection.

Candida albicans is a fungus that can be found in small quantities on the skin and mucous membranes, along with a few bacteria. This entire microbial population co-exists without causing health problems. During antibacterial antibiotic treatments, which cystic fibrosis patients undergo frequently, the bacterial flora are reduced while fungi such as Candida albicans proliferate. This creates a local inflammation in the vulva-vaginal area, causing redness, discomfort, pruritis and discharge. Candida infections may also be found on the glans penis. The condition can quickly be cured by stopping the antibiotics with or without the addition of an antifungal antibiotic. Cortisone also promotes this type of infection. Candida can also affect skin folds where humidity occurs (the groin and the area under the breasts). It can be found in the mouth and pharynx and sometimes in the esophagus. The treatment depends on the location of the problem. Antifungal antibiotics can be used topically (creams, ointments and vaginal suppositories) or systemically with pills, an oral suspension or intravenously.

Candida vaginitis symptoms may appear following an antibiotic treatment. To prevent this from occurring, physicians may prescribe an antibacterial antibiotic concurrently with an antifungal antibiotic.

HEALTH COLUMN
SVB/ 2006, No 29, page 38

Childhood diseases (smallpox, measles, German measles, mumps, etc.)

Last month, my niece, who lives with me and my family, contracted chickenpox. I panicked at the thought of catching this disease. Was I right to be afraid? Are persons with cystic fibrosis more likely to be affected by this type of virus than other people? Is it even more dangerous for people who have had a lung transplant? Are some childhood diseases (smallpox, measles, German measles, mumps, etc.) more threatening than others? What prevention measures do you recommend for persons with cystic fibrosis?

Most adults have already had chickenpox in childhood and those who have had it cannot get it a second time. However, you should be aware that shingles (herpes zoster) is a disease caused by the same virus that invades the body when you have chickenpox, but it remains on the nerve roots where it is contained by the immune system. When the immune system is low, the virus can travel along the nerve to the skin and cause shingles.

The minority of adults who have never had chickenpox are at risk of contracting it when they come in contact with a person who carries the chickenpox or herpes zoster virus. Persons with cystic fibrosis are not more likely to contract the disease than other people because they have good immune systems. However, all adults (whether or not they have cystic fibrosis) who catch chickenpox usually have very severe symptoms and may even get pneumonia from this virus. Cystic fibrosis patients with serious lung involvement risk being quite ill if they catch pneumonia through the chickenpox virus. People who have never had chickenpox and contract the virus after they have had a transplant are at risk of suffering even more from the disease because of immunosuppression. However, a chickenpox vaccine is now offered to all children. It might be appropriate for adults with cystic fibrosis who have never had chickenpox to be vaccinated before they receive a lung or liver transplant.

As for the other viral infections mentioned in your question, smallpox was officially eradicated from the planet, so this vaccination is no longer necessary and is not offered any more. Safe and effective vaccinations against measles, German measles and mumps are part of the immunization schedules for children in Quebec. A single vaccine covers all three diseases; it is given in two doses and children receive the first dose when they are one year old.

HEALTH COLUMN
SVB/ 2006, No 29, pages 38-39

Super anti-inflammatory drugs (Vioxx^TM, Celebrex^TM and Bextra^TM)

I’m very worried about all the controversy over super anti-inflammatory drugs (Vioxx^TM, Celebrex^TM and Bextra^TM). Vioxx has been a miracle drug for me. Why is it so controversial? Should persons with cystic fibrosis be concerned about the undesirable effects of this drug?

The anti-inflammatories in question (Vioxx^TM, Celebrex^TM and Bextra^TM) are in the COX-2 inhibitor class of drugs, as opposed to conventional anti-inflammatory drugs, which are both COX-1 and COX-2 inhibitors. COX-2 inhibitors are not really super anti-inflammatory drugs in that their anti-inflammatory effect is not better than that of conventional anti-inflammatories (Advil^TM, Naprosyn^®, Voltaren^®, Indocid^TM, etc.). The advantage of COX-2 inhibitors is that the risk of gastro-intestinal toxicity is lower than it is with conventional anti-inflammatory drugs: they cause less acidity, fewer ulcers and less gastro-intestinal bleeding in the stomach and duodenum.

The reason Vioxx^TM was withdrawn is that studies conducted after it was marketed showed an increased incidence of cardiovascular problems. This can be explained by the fact that the selectivity of COX-2 inhibitors reduces anticoagulant properties in the blood vessels and platelets. Bextra has just been taken off the market, not only because of the cardiovascular risks, but also because it causes skin problems. Celebrex^TM is still on the market, but it is being closely monitored because it may cause similar undesirable effects to those of Vioxx^TM. It is clear, however, that the incidence of undesirable cardiovascular effects is much higher in people who already have cardiovascular risk factors (old age, smoking, elevated cholesterol and high blood pressure), which is not the case for the majority of the cystic fibrosis population. Patients with cystic fibrosis who need an anti-inflammatory drug and who do not have a cardiovascular risk factor could take Celebrex^TM. They could also take conventional anti-inflammatory drugs along with a drug that provides gastric protection.

HEALTH COLUMN
SVB/ 2006, No 29, page 39