***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: Our goal was to assess the role of early childhood vaccination in the occurrence of respiratory symptoms and allergic sensitization in 7 - 8-year-old Dutch and German children . A nested case-control study was conducted among children participating in a large longitudinal study on respiratory health , to study the relationship between vaccination ( bacille Calmette-Guérin ( BCG ) , pertussis , measles/mumps , rubella , and Haemophilus influenza type b ( Hib ) ) and respiratory symptoms and allergic sensitization .  Parents of 510 7 - 8-year-old children with respiratory complaints and an equal number of r and omly selected children without respiratory complaints were asked to complete a question naire . Blood sample s were collected for specific serum IgE analysis . Vaccination status was assessed through the records of the participating Municipal Health Services . No association between vaccination against pertussis , measles , rubella , or Hib and respiratory symptoms or allergic sensitization was found . For sensitization against house dust mite ,  BCG vaccination result ed in an increased risk ( OR , 2.28 ; 95 % CI , 1.05 - 4.96 ) . Birth order was inversely associated with allergic sensitization , but was not related to respiratory symptoms . We found an association between  BCG vaccination  and the subsequent risk for sensitization against house dust mite . No evidence was found for an association between vaccination and respiratory symptoms . Earlier reports of an association of birth order with atopic disease were supported by the results of the present study BACKGROUND Inhaled hypertonic saline acutely increases mucociliary clearance and , in short-term trials , improves lung function in people with cystic fibrosis . We tested the safety and efficacy of inhaled hypertonic saline in a long-term trial . METHODS In this double-blind , parallel-group trial , 164 patients with stable cystic fibrosis who were at least six years old were r and omly assigned to inhale 4 ml of either 7 percent hypertonic saline or 0.9 percent ( control ) saline twice daily for 48 weeks , with quinine sulfate ( 0.25 mg per milliliter ) added to each solution to mask the taste . A bronchodilator was given before each dose , and other st and ard therapies were continued during the trial . RESULTS The primary outcome measure , the rate of change ( slope ) in lung function ( reflected by the forced vital capacity [ FVC ] , forced expiratory volume in one second [ FEV1 ] , and forced expiratory flow at 25 to 75 percent of FVC [ FEF25 - 75 ] ) during the 48 weeks of treatment , did not differ significantly between groups ( P=0.79 ) . However , the absolute difference in lung function between groups was significant ( P=0.03 ) when averaged across all post-r and omization visits in the 48-week treatment period . As compared with the control group , the hypertonic-saline group had significantly higher FVC ( by 82 ml ; 95 percent confidence interval , 12 to 153 ) and FEV1 ( by 68 ml ; 95 percent confidence interval , 3 to 132 ) values , but similar FEF25 - 75 values . The hypertonic-saline group also had significantly fewer pulmonary exacerbations ( relative reduction , 56 percent ; P=0.02 ) and a significantly higher percentage of patients without exacerbations ( 76 percent , as compared with 62 percent in the control group ; P=0.03 ) . Hypertonic saline was not associated with worsening bacterial infection or inflammation . CONCLUSIONS Hypertonic saline preceded by a bronchodilator is an inexpensive , safe , and effective additional therapy for patients with cystic fibrosis . ( Clinical Trials.gov number , NCT00271310 . It has been postulated that hypertonic saline ( HS ) might impair the antimicrobial effects of defensins within the airways . Alternative non-ionic osmotic agents such as mannitol may thus be preferable to HS in promoting bronchial mucus clearance ( BMC ) in patients with cystic fibrosis ( CF ) . This study reports the effect of inhalation of another osmotic agent , dry powder Mannitol ( 300 mg ) , compared with its control ( empty capsules plus matched voluntary cough ) and a 6 % solution of HS on BMC in 12 patients with cystic fibrosis ( CF ) .  Mucus clearance was measured using a radioaerosol/gamma camera technique . Post-intervention clearance was measured for 60 min , followed by cough clearance for 30 min . Neither mannitol nor HS improved BMC during the actual intervention period compared with their respective controls . However during the post-intervention measurement there was a significant improvement in BMC for both the mannitol ( 8.7+/-3.3 % versus 2.8+/-0.7 % ) and HS ( 10.0+/-2.3 % versus 3.5+/-0.8 % ) . There was also a significant improvement in cough clearance with the Mannitol ( 9.7+/-2.4 % ) compared with its control ( 2.5+/-0.8 % ) . Despite premedication with a bronchodilator , a small fall in forced expiratory volume in one second ( FEV1 ) was seen immediately after administration of both the mannitol ( 7.3+/-2.5 % ) and HS ( 5.8+/-1.2 % ) . Values of FEV1 returned to baseline by the end of the study . Inhaled mannitol is a potential mucoactive agent in cystic fibrosis patients . Further studies are required to establish the optimal dose and the long-term effectiveness of mannitol Background and aims Sensitive outcome measures to assess the efficacy of therapeutic interventions in patients with cystic fibrosis ( CF ) with mild lung disease are currently lacking . Our objective was to study the ability of the lung clearance index ( LCI ) , a measure of ventilation inhomogeneity , to detect a treatment response to hypertonic saline inhalation in paediatric patients with CF with normal spirometry . Methods In a crossover trial , 20 patients with CF received 4 weeks of hypertonic saline ( HS ) and isotonic saline ( IS ) in a r and omised sequence separated by a 4 week washout period . The primary end point was the change in the LCI due to HS versus IS . Results Baseline characteristics including the LCI were not significantly different between both study periods . Four weeks of twice-daily HS inhalation significantly improved the LCI compared with IS ( 1.16 , 95 % CI 0.26 to 2.05 ; p=0.016 ) , whereas other outcome measures such as spirometry and quality of life failed to reach statistical significance . R and omisation order had no significant impact on the treatment effect . Conclusions The LCI , but not spirometry was able to detect a treatment effect from HS inhalation in patients with CF with mild disease and may be a suitable tool to assess early intervention strategies in this patient population . Clinical trial number NCT00635141 Cystic fibrosis ( CF ) is the most frequent lethal autosomal recessive disease among Caucasians . In more than 90 % of all patients the pulmonary involvement is the life-limiting factor . In the lung , the production of viscous sputum is a main and early clinical feature of CF . To help clear the lungs from this material mucolytic active drugs were used . Recombinant human DNase ( rhDNase ) w1x and hypertonic ( 5.85 % ) saline ( HS ) w2x both were mucolytic active and improved FEV1 in the same range in patients with CF . Besides this similarity there are differences such as the modulation of rheological parameters and costs . To determine whether these treatments can replace each other , we compared effect and acceptance in the same group of patients BACKGROUND Abnormal homeostasis of the volume of airway surface liquid in patients with cystic fibrosis is thought to produce defects in mucus clearance and airway defense . Through osmotic forces , hypertonic saline may increase the volume of airway surface liquid , restore mucus clearance , and improve lung function . METHODS A total of 24 patients with cystic fibrosis were r and omly assigned to receive treatment with inhaled hypertonic saline ( 5 ml of 7 percent sodium chloride ) four times daily with or without pretreatment with amiloride .  Mucus clearance and lung function were measured during 14-day baseline and treatment periods . RESULTS Long-term inhalation of hypertonic saline without pretreatment with amiloride ( i.e. , with placebo pretreatment ) result ed in a sustained ( > or = 8 hours ) increase in 1-hour rates of mucus clearance , as compared with those with amiloride pretreatment ( 14.0+/-2.0 vs. 7.0+/-1.5 percent , respectively ; P=0.02 ) and increased 24-hour rates of mucus clearance over baseline . Furthermore , inhalation of hypertonic saline with placebo improved the forced expiratory volume in one second ( FEV1 ) between the baseline period and the treatment period ( mean difference , 6.62 percent ; 95 percent confidence interval , 1.6 to 11.7 ; P=0.02 ) , whereas hypertonic saline with amiloride did not improve FEV1 ( mean difference , 2.9 percent ; 95 percent confidence interval , -2.2 to 8.0 ; P=0.23 ) . Forced vital capacity ( FVC ) , the forced expiratory flow between 25 and 75 percent of FVC ( FEF25 - 75 ) , and respiratory symptoms also significantly improved in patients treated with hypertonic saline and placebo , whereas the residual volume as a proportion of total lung capacity ( RV : TLC ) did not change in either group . A comparison of the changes in lung function in the two groups showed no significant difference . In vitro data suggested that sustained hydration of airway surfaces was responsible for the sustained improvement in mucus clearance , whereas inhibition of osmotically driven water transport by amiloride accounted for the observed loss of clinical benefit . CONCLUSIONS In patients with cystic fibrosis , inhalation of hypertonic saline produced a sustained acceleration of mucus clearance and improved lung function . This treatment may protect the lung from insults that reduce mucus clearance and produce lung disease OBJECTIVES This study compared the relative cost-effectiveness of daily recombinant human deoxyribonuclease ( rhDNase ) , with alternate day rhDNase and hypertonic saline ( HS ) for treating children with cystic fibrosis ( CF ) . METHODS A r and omized controlled trial with a crossover design allocated 40 CF children consecutively to 12 weeks of daily rhDNase , alternate day rhDNase , or HS . The primary outcome measure was forced expiratory volume in 1 second ( FEV1 ) , a measure of lung function . All health re source use was prospect ively documented for each patient and multiplied by unit costs to give a total health service cost for each 12-week treatment period . The nonparametric bootstrap method was used to present cost-effectiveness acceptability curves and net benefit statistics for each treatment comparison , for various hypothetical levels of the decision maker 's ceiling ratio . RESULTS Compared with HS , there was a 14 % improvement in FEV1 for daily rhDNase ( 95 % Cl , 5 % to 23 % ) , and a 12 % improvement ( 95 % Cl , 2 % to 22 % ) for alternate day rhDNase . For a ceiling ratio of 200 pounds sterling per 1 % gain in FEV1 , the mean net benefits of daily and alternate day rhDNase compared with HS were 1,158 pounds sterling ( 95 % Cl , -621pounds sterling to 2,842 ) and 1,188 pounds sterling ( 95 % Cl , -847 to 3,343 ) , respectively ; the mean net benefit of daily compared with alternate day rhDNase was -30 pounds sterling ( 95 % Cl , -2,091 pounds sterling to 1,576 ) . CONCLUSIONS If decision makers are prepared to pay 200 pounds sterling for a 1 % gain in FEV1 over a 12-week period , then on average either rhDNase strategy is cost-effective Twenty-seven patients with cystic fibrosis completed a controlled trial comparing the effects of an inhaled mucolytic drug , sodium-2-mercaptoethane sulphonate ( Mistabron , UCB Pharmaceutical Division , Brussels , Belgium ) , with inhaled iso-osmolar hypertonic saline . As a group the 22 patients with chronic sputum production showed small but statistically significant improvement in pulmonary function tests after Mistabron therapy , both when compared with a control period , and with iso-osmolar saline results . Subjective measurements by diary card failed to show any changes . No significant changes were found in five patients with no measurable sputum production . The inhalations were given after physiotherapy and were well tolerated . There were no significant side effects . The results suggest that Mistabron has a beneficial therapeutic effect unrelated to its high osmolality , and the intermittent inhalation of Mistabron may have a role in the treatment of selected patients with cystic fibrosis Background : Chest physiotherapy has been used for many years to assist in the removal of abnormal viscid bronchial secretions in cystic fibrosis ( CF ) patients . Objectives : This study compared the short-term effects of two physiotherapy regimens in patients with CF :  autogenic drainage ( AD ) preceded by either saline inhalation ( ‘ salineNEB + AD ’ ) or by intrapulmonary percussive ventilation ( IPV ) with saline ( ‘ salineIPV + AD ’ ) 
    Output:
    
Unlike RhDNAse , HS ca n't , in the long term , be said to improve lung function .
However , it did improve quality of life and reduce pulmonary exacerbations .
Delivered following a bronchodilator , HS appears inexpensive and safe with no increased infection risk .
We believe there is sufficient evidence to recommend using HS in CF ; qualifying this we highlight that the only long-term trial failed to demonstrate a significant difference in its primary outcome ( lung function ) with improvements only in secondary outcomes