<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT04476758</url>
  </required_header>
  <id_info>
    <org_study_id>20-0099</org_study_id>
    <nct_id>NCT04476758</nct_id>
  </id_info>
  <brief_title>Immune Profiles in CF Fungal Infection</brief_title>
  <official_title>Immune Profiles in CF Fungal Infection</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>University of Alabama at Birmingham</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
    <collaborator>
      <agency>University of Colorado, Denver</agency>
      <agency_class>Other</agency_class>
    </collaborator>
  </sponsors>
  <source>University of Alabama at Birmingham</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
  </oversight_info>
  <brief_summary>
    <textblock>
      This study is investigating the role of allergic (Th2) inflammation in patients with Cystic&#xD;
      Fibrosis (CF) and history of fungal infection and/or Allergic Bronchopulmonary Aspergillosis.&#xD;
      Little is known about fungal infection in CF and conflicting results exist on whether this&#xD;
      results in worse lung function over time. There is concern that persistent fungal infection&#xD;
      can result in worse clinical outcome measures in patients with CF. Also, it is unclear how&#xD;
      ABPA develops, but may be related to the amount of fungus a patient with CF is infected with.&#xD;
      This study looks at inflammatory patterns and allergic responses to fungal elements to help&#xD;
      identify biomarkers and signs of allergic disease in fungally infected patients with CF.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      While bacteria are predominant agents in CF lung disease, fungi are often isolated in both&#xD;
      sputum and bronchoalveolar lavage fluid (BAL), yet their role in CF is not fully understood.&#xD;
      Fungal infection in CF has a wide spectrum of presentations, varying from transient detection&#xD;
      to persistent infection, acute fungal bronchitis with resulting pulmonary exacerbation,&#xD;
      sensitization to fungal allergens, and allergic bronchopulmonary aspergillosis (ABPA). While&#xD;
      there are clinical guidelines for the diagnosis and treatment of ABPA in patients with CF,&#xD;
      there are few guidelines and recommendations regarding monitoring, clinical care, and&#xD;
      antifungal treatment in the various presentations of CF fungal disease; further, the clinical&#xD;
      impact of fungi without ABPA is poorly understood. While inflammation in CF is classically&#xD;
      considered a neutrophil and macrophage driven process (Th1), eosinophils and allergic&#xD;
      cytokines (Th2) have been shown to be elevated in the presence of fungal disease in both&#xD;
      clinical and animal CF studies. Studies have also shown decreased lung function (e.g. percent&#xD;
      predicted forced expiratory volume in one second, ppFEV1) in individuals with frequent fungal&#xD;
      detection in their sputum, and associations with Pseudomonas infection and use of&#xD;
      antimicrobials. Adults with CF are also more prone to fungal sensitization when compared to&#xD;
      non-CF patients as well as having higher rates of allergic rhinitis and atopy. In a&#xD;
      retrospective study performed at our center, we found that children with intermittent or&#xD;
      chronic fungal infections experienced more rapid decline in lung function compared to those&#xD;
      without fungal infections regardless of ABPA status (see preliminary data). Understanding&#xD;
      whether fungal infections are driven by an allergic (Th2) inflammatory process may alter&#xD;
      treatment approaches by utilizing steroids and antifungal therapies more readily in patients&#xD;
      with fungal infection to combat lung function decline. Limited studies have investigated the&#xD;
      frequency of allergic sensitization to fungal pathogens in individuals with CF, the frequency&#xD;
      of allergic sensitization in the pediatric CF population in general, and the unique&#xD;
      inflammatory profiles and phenotypes of CF fungal infections, both in the sputum and the&#xD;
      serum.&#xD;
&#xD;
      Hypothesis: We hypothesize that children with CF and fungal infections without ABPA will have&#xD;
      elevated allergic inflammatory profiles and increased sensitization to fungal elements&#xD;
      compared to those without fungal infection.&#xD;
&#xD;
      Specific Aim 1: Compare Th2 inflammation in patients with and without fungal infections in&#xD;
      patients with CF and to those with ABPA.&#xD;
&#xD;
        -  Approach: We will obtain serum and sputum samples from 25 patients with either (1)&#xD;
           fungal infection without ABPA, n=10 (defined as ≥ two positive fungal cultures in prior&#xD;
           18 months), (2) no fungal infection, n=10, and (3) ABPA, n=5, and measure specific&#xD;
           sputum and serum cytokine measurements to evaluate Th2 and Th1 inflammatory pathways.&#xD;
&#xD;
        -  Biomarkers measured: Eosinophilic cationic protein (ECP), Interleukin-4 (IL4),&#xD;
           Interleukin-5 (IL5), Interleukin-10 (IL10), Interleukin-13 (IL13), and eosinophil count&#xD;
           in both serum and sputum.&#xD;
&#xD;
        -  Expected outcome: Individuals with fungal infection without APBA will have elevated Th2&#xD;
           markers of inflammation compared to those with no fungal infection. We will also compare&#xD;
           to those with ABPA as a separate control group. We will also measure Th1 markers to be&#xD;
           used as a reference to previously established inflammatory profiles seen in CF, seeing&#xD;
           if those with fungal disease deviate towards a more Th2 driven process.&#xD;
&#xD;
      Specific Aim 2: Investigate allergic sensitization to fungal elements in patients with CF&#xD;
      fungal infection without ABPA compared to those without fungal infection and to those with&#xD;
      ABPA.&#xD;
&#xD;
        -  Approach: We will measure total IgE and serum ImmunoCAP testing of specific IgE levels&#xD;
           to fungal proteins of various species (Aspergillus, Candida, etc). to determine fungal&#xD;
           sensitization. We will also survey patients regarding environmental exposures to explore&#xD;
           relationships with allergic sensitization.&#xD;
&#xD;
        -  Expected outcome: Individuals with fungal infection without ABPA will be more likely to&#xD;
           show allergic sensitization to fungal elements when compared to those with no fungal&#xD;
           infection.&#xD;
&#xD;
      The results of this study will help characterize the inflammatory profile associated with CF&#xD;
      fungal infections contributing to the understanding of both the infectious and allergic&#xD;
      nature of disease in the CF population. From this, the contribution to both the&#xD;
      pathophysiology and clinical characteristics of CF fungal infections will serve as a step&#xD;
      towards understanding management options, care guidelines, and disease progression for this&#xD;
      unique set of hard to treat organisms.&#xD;
&#xD;
      Recruitment: We propose to recruit 25 patients with CF aged between 8 and 25 years who agree&#xD;
      to participate in this cross-sectional study looking at the immune system characteristics of&#xD;
      fungal infection and ABPA. We plan to screen individuals coming to their routine CF clinic&#xD;
      and approach them regarding their interest in participating in this study. From this, we will&#xD;
      explain the concept, hypothesis, and procedures involved with intent to schedule them for a&#xD;
      research visit.&#xD;
&#xD;
      Patient Selection: Patients will be recruited from the CF Center at CHCO by study&#xD;
      investigators or qualified research coordinators at the time of a routine clinic visit.&#xD;
&#xD;
      Study Visit: We plan to prospectively recruit 25 subjects with CF during a period of clinical&#xD;
      stability. Subjects will have one research clinic visit that will coincide with their clinic&#xD;
      visit at CHCO Pulmonary Clinic facilities. The following diagnostic information will be&#xD;
      entered onto Case Report Forms: demographic information, diagnostic history and mutations,&#xD;
      CF-related co-morbidities, historic microbiology results including fungal culture results,&#xD;
      medications including modulator therapy and long-term antibiotic regimens, previous allergy&#xD;
      testing, diagnostic criteria for ABPA (if applicable). We will also utilize historical&#xD;
      clinical data from the medical record to establish other co-morbidities, lung function trends&#xD;
      and baseline, history of other bacterial infections, history of allergy diagnoses, and other&#xD;
      pertinent medical history and diagnostic testing (ie previous CT scan results, previous blood&#xD;
      work, etc.). The following evaluations will be performed :&#xD;
&#xD;
        -  Historical data in the medical record. Examples include Co-morbid diagnoses related to&#xD;
           CF (such as but not limited to CF related diabetes, CF liver disease, asthma, etc),&#xD;
           previous blood work (such as but not limited to serum IgE levels, previous allergy&#xD;
           testing, bronchoscopy data and lavage studies, routine and urgent/admission CF labs,&#xD;
           etc), previous spirometery and lung function data, previous nutritional and growth data&#xD;
           (BMI, vitamin levels, etc), previous microbiology and culture data, etc.&#xD;
&#xD;
        -  BMI measurements obtained from regular CF clinic visit&#xD;
&#xD;
        -  Height and weight to be obtained and subsequently calculated.&#xD;
&#xD;
        -  Pulmonary function testing obtained from regular CF clinic visit. Spirometry will be&#xD;
           performed according to American Thoracic Society criteria, while absolute values will be&#xD;
           converted to percent predicted using the Global Lung Function initiative reference&#xD;
           equations34.&#xD;
&#xD;
        -  Sputum collection. Spontaneously expectorated sputum will be used as possible.This will&#xD;
           be collected at home by the patient following a routine respiratory airway clearance&#xD;
           regimen within 12 hours of clinic visit. The sample will be placed in a mailed specimen&#xD;
           cup and placed on ice and brought to the clinic visit. If sputum is not able to be&#xD;
           expectorated prior to visit, we will attempt to utilize remaining sputum expectorated&#xD;
           that is not used for clinical needs for further analysis and storage. Sputum may be&#xD;
           collected by sputum induction according to the current CFF Therapeutics Development&#xD;
           Network standard operating procedure if 1) unable to expectorate, (2) patient meets&#xD;
           clinical criteria for sputum induction and (3) clinic is able to perform research&#xD;
           induced sputum based on current COVID-19 guidelines to ensure safety of team member and&#xD;
           adequate PPE supply.&#xD;
&#xD;
      For safety reasons, the induction procedures will only be performed for subjects who meet the&#xD;
      following criteria on the day of the induction: FEV1 ≥ 30% predicted, No history of &gt; 5 mL&#xD;
      hemoptysis within 48 hours prior to the visit, Able to tolerate the sputum induction&#xD;
      procedure. Of note, there is little significant difference in specimen quality for analysis&#xD;
      between expectorated and induced sputum. Markers to be tested as previously described above.&#xD;
&#xD;
        -  Environmental fungal exposure questionnaire. Will be performed prior to finish of clinic&#xD;
           visit. This questionnaire in entirety is a validated questionnaire used by Dr. Andy Liu.&#xD;
           Given time constraints for study participants, we are using a modified questionnaire&#xD;
           focused on questions of interested to this study (e.g. pertaining to fungal exposure).&#xD;
           This has not been validated but may provide important information in this pilot study&#xD;
           for future research&#xD;
&#xD;
        -  Serum collection. Peripheral venous blood draw will be performed by certified individual&#xD;
           using appropriate sterile technique by the CTRC. Samples will be labeled per research&#xD;
           protocol standards. Markers to be tested described above.&#xD;
&#xD;
             -  All sputum samples to be banked and saved for potential microbiome, mycobiome and&#xD;
                transcriptome analysis, assessing gene expressions unique to various inflammatory&#xD;
                pathways.&#xD;
&#xD;
      Sample Size Estimates: Power and sample size for the study proposal is fixed due to the&#xD;
      expected number of eligible patients to be recruited into this pilot study during the study&#xD;
      window. Based on preliminary data and the described definitions of types of infection,&#xD;
      investigators anticipate that over a 1-year recruitment window they will be able to enroll&#xD;
      approximately 10 individuals with no fungal infection, 10 patients with a fungal infection&#xD;
      but not ABPA and 5 with ABPA. The primary analysis plan focuses on the description and&#xD;
      comparison of key plasma and sputum measures described in Table 3. Power analysis provides&#xD;
      the detectable effect sizes when comparing the control arm (no fungal infection) to either&#xD;
      the non-ABPA group or the ABPA group. Calculations are based on a power of 80% and Type I&#xD;
      error rate of 0.05 for two-sided two-sample equal-variance t-test conducted in PASS version&#xD;
      15 statistical software (2). Group sample sizes of 10 and 5 in the fungal infection groups&#xD;
      achieve 80% power to reject the null hypothesis of zero effect size when the population&#xD;
      effect size is 1.36 and 1.66 respectively. Thus, the study is powered at 80% to detect a&#xD;
      difference in the mean markers to be measured greater than 1.66 and 1.32 standard deviations.&#xD;
      Given limited data in the literature regarding Th2 markers in CF, we are basing these&#xD;
      calculations off of deviations from a mean for the multiple Th2 markers we are testing.&#xD;
&#xD;
      Data Collection and Storage: All subjects will be de-identified upon study sample collection&#xD;
      and stored with a master key. There will be limited access to this information with the PI&#xD;
      and only essential research staff able to monitor and view the data. All hardcopy source&#xD;
      documents will be kept in a locked file cabinet in the CF research team's storage facilities.&#xD;
      Additionally, to further ensure data integrity, data for this study will be stored in&#xD;
      Research Electronic Data Capture system (REDCap), which will allow limited access to only&#xD;
      essential personal. REDCap enables in-line validation to minimize transcription errors and&#xD;
      provides real-time notifications of data submission and allows immediate central monitoring&#xD;
      and feedback. Access to data requires an encrypted secure socket layer (SSL) connection and&#xD;
      changes are logged by user ID, time stamp and project. Databases are backed up frequently.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Enrolling by invitation</overall_status>
  <start_date type="Actual">February 10, 2021</start_date>
  <completion_date type="Anticipated">October 31, 2023</completion_date>
  <primary_completion_date type="Anticipated">October 31, 2023</primary_completion_date>
  <study_type>Observational</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <observational_model>Cohort</observational_model>
    <time_perspective>Cross-Sectional</time_perspective>
  </study_design_info>
  <primary_outcome>
    <measure>Difference in Th2 Sputum Markers</measure>
    <time_frame>Day 1</time_frame>
    <description>Difference in sputum Th2 biomarkers (ECP, IL4, IL5, IL10, IL13, and eosinophil count) in patients with CF with fungal infection with expected elevation of sputum Th2 biomarkers in patients with CF and ABPA compared to those without fungal infection and without ABPA.</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>Other markers of fungal inflammation and allergic reaction in patients with CF</measure>
    <time_frame>Day 1</time_frame>
    <description>Serum Th2 biomarkers in patients with fungal infection and ABPA (Table 3).&#xD;
Serum Th1 biomarkers in patients with fungal infection and ABPA (Table 3).&#xD;
Serum sensitization markers to fungal allergens in patients with fungal infection and ABPA (Table 4).&#xD;
Baseline and historic lung function, historical comorbid diagnoses and BMI measurements in patients with fungal infection and ABPA.&#xD;
Environmental factors that are possibly related to fungal infection and ABPA in patients with CF.&#xD;
Immune profile: A profile of each group will be based upon their findings of each set of biomarkers: Th1, Th2, mold allergy panel, and systemic markers of inflammation. Based upon findings in each of these categories (elevated, depressed), we will be able to formulate a profile based upon the type of marker/inflammatory pathway.</description>
  </secondary_outcome>
  <other_outcome>
    <measure>Biobanking of specimens</measure>
    <time_frame>Day 1</time_frame>
    <description>Banking of both sputum and serum to potentially utilize microbiome and transcriptome techniques for further immunotyping and infection characterization.</description>
  </other_outcome>
  <number_of_groups>3</number_of_groups>
  <enrollment type="Anticipated">25</enrollment>
  <condition>Cystic Fibrosis</condition>
  <condition>Fungal Infection</condition>
  <condition>Allergic Bronchopulmonary Aspergillosis</condition>
  <arm_group>
    <arm_group_label>Fungal Infection Group</arm_group_label>
    <description>Have had a fungal species isolated from sputum and/or BAL culture on &gt;= 2 separate occasions in the 18 months preceding study visit and do not have a diagnosis of ABPA (N=10).</description>
  </arm_group>
  <arm_group>
    <arm_group_label>Control Group</arm_group_label>
    <description>Have never previously isolated fungus from sputum, BAL, or OP swab (N=10).</description>
  </arm_group>
  <arm_group>
    <arm_group_label>ABPA Group</arm_group_label>
    <description>Previous diagnosis of ABPA as defined by CFF guidelines, regardless of the amount of fungal infection or history thereof.&#xD;
• ABPA Minimum diagnostic criteria per CFF: Acute or subacute deterioration, total serum IgE &gt; 500 IU per mL, immediate cutaneous reactivity to Aspergillus or in vitro IgE antibody to A. fumigatus, and either a new or recent chest imaging change that has not responded to antibiotics and standard physiotherapy OR precipitin to A. fumigatus or IgG antibody to A. fumigatus1 (N=5). Culture positive sputum is not required for ABPA diagnosis and is not taken into account for the diagnosis per CFF guidelines.</description>
  </arm_group>
  <biospec_retention>Samples With DNA</biospec_retention>
  <biospec_descr>
    <textblock>
      Sputum and serum from subjects&#xD;
    </textblock>
  </biospec_descr>
  <eligibility>
    <study_pop>
      <textblock>
        Pediatric to young adult patients with CF followed at Children's Hospital Colorado.&#xD;
        Patients must meet inclusion/exclusion criteria and fit into one of the three groups&#xD;
        described.&#xD;
      </textblock>
    </study_pop>
    <sampling_method>Non-Probability Sample</sampling_method>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  Diagnosis of CF per CFF guidelines and followed at Children's Hospital Colorado (CHCO)&#xD;
             CF Center&#xD;
&#xD;
          -  Meets criteria of only one fungal group (described below)&#xD;
&#xD;
          -  Clinical stability without any change acute antibiotic regimen in the past 14 days&#xD;
&#xD;
          -  Clinical stability without any use for acute NSAID or oral steroids in past 14 days&#xD;
&#xD;
          -  Individuals with other co-morbid conditions related to and unrelated to CF, including&#xD;
             but not limited to CF related diabetes, CF related liver disease, asthma, etc.&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  History of Burkholderia sp. or Non-tuberculosis Mycobacterium&#xD;
&#xD;
          -  Comorbid or health contraindication to induced sputum treatment or blood draw&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>8 Years</minimum_age>
    <maximum_age>25 Years</maximum_age>
  </eligibility>
  <overall_official>
    <last_name>Thomas S Poore, MD</last_name>
    <role>Principal Investigator</role>
    <affiliation>University of Colorado, Denver</affiliation>
  </overall_official>
  <location>
    <facility>
      <name>Childrens Hospital Colorado</name>
      <address>
        <city>Highlands Ranch</city>
        <state>Colorado</state>
        <zip>80310</zip>
        <country>United States</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>United States</country>
  </location_countries>
  <verification_date>October 2022</verification_date>
  <study_first_submitted>July 8, 2020</study_first_submitted>
  <study_first_submitted_qc>July 14, 2020</study_first_submitted_qc>
  <study_first_posted type="Actual">July 20, 2020</study_first_posted>
  <last_update_submitted>October 31, 2022</last_update_submitted>
  <last_update_submitted_qc>October 31, 2022</last_update_submitted_qc>
  <last_update_posted type="Actual">November 2, 2022</last_update_posted>
  <responsible_party>
    <responsible_party_type>Principal Investigator</responsible_party_type>
    <investigator_affiliation>University of Alabama at Birmingham</investigator_affiliation>
    <investigator_full_name>Thomas Spencer Poore</investigator_full_name>
    <investigator_title>Assistant Professor</investigator_title>
  </responsible_party>
  <keyword>Fungal Infection</keyword>
  <keyword>Th2 Inflammation</keyword>
  <keyword>Cystic Fibrosis</keyword>
  <keyword>Fungal allergy</keyword>
  <keyword>Allergic Bronchopulmonary Aspergillosis</keyword>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Infections</mesh_term>
    <mesh_term>Communicable Diseases</mesh_term>
    <mesh_term>Mycoses</mesh_term>
    <mesh_term>Aspergillosis</mesh_term>
    <mesh_term>Pulmonary Aspergillosis</mesh_term>
    <mesh_term>Aspergillosis, Allergic Bronchopulmonary</mesh_term>
    <mesh_term>Cystic Fibrosis</mesh_term>
    <mesh_term>Fibrosis</mesh_term>
  </condition_browse>
  <provided_document_section>
    <provided_document>
      <document_type>Study Protocol and Statistical Analysis Plan</document_type>
      <document_has_protocol>Yes</document_has_protocol>
      <document_has_icf>No</document_has_icf>
      <document_has_sap>Yes</document_has_sap>
      <document_date>June 10, 2020</document_date>
      <document_url>https://ClinicalTrials.gov/ProvidedDocs/58/NCT04476758/Prot_SAP_000.pdf</document_url>
    </provided_document>
    <provided_document>
      <document_type>Informed Consent Form</document_type>
      <document_has_protocol>No</document_has_protocol>
      <document_has_icf>Yes</document_has_icf>
      <document_has_sap>No</document_has_sap>
      <document_date>June 10, 2020</document_date>
      <document_url>https://ClinicalTrials.gov/ProvidedDocs/58/NCT04476758/ICF_001.pdf</document_url>
    </provided_document>
  </provided_document_section>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT04476758
org study id: 20-0099
nct id: NCT04476758
lead sponsor: 
collaborator: 
has dmc: No
is fda regulated drug: No
is fda regulated device: No
This study is investigating the role of allergic (Th2) inflammation in patients with Cystic
      Fibrosis (CF) and history of fungal infection and/or Allergic Bronchopulmonary Aspergillosis.
      Little is known about fungal infection in CF and conflicting results exist on whether this
      results in worse lung function over time. There is concern that persistent fungal infection
      can result in worse clinical outcome measures in patients with CF. Also, it is unclear how
      ABPA develops, but may be related to the amount of fungus a patient with CF is infected with.
      This study looks at inflammatory patterns and allergic responses to fungal elements to help
      identify biomarkers and signs of allergic disease in fungally infected patients with CF.
While bacteria are predominant agents in CF lung disease, fungi are often isolated in both
      sputum and bronchoalveolar lavage fluid (BAL), yet their role in CF is not fully understood.
      Fungal infection in CF has a wide spectrum of presentations, varying from transient detection
      to persistent infection, acute fungal bronchitis with resulting pulmonary exacerbation,
      sensitization to fungal allergens, and allergic bronchopulmonary aspergillosis (ABPA). While
      there are clinical guidelines for the diagnosis and treatment of ABPA in patients with CF,
      there are few guidelines and recommendations regarding monitoring, clinical care, and
      antifungal treatment in the various presentations of CF fungal disease; further, the clinical
      impact of fungi without ABPA is poorly understood. While inflammation in CF is classically
      considered a neutrophil and macrophage driven process (Th1), eosinophils and allergic
      cytokines (Th2) have been shown to be elevated in the presence of fungal disease in both
      clinical and animal CF studies. Studies have also shown decreased lung function (e.g. percent
      predicted forced expiratory volume in one second, ppFEV1) in individuals with frequent fungal
      detection in their sputum, and associations with Pseudomonas infection and use of
      antimicrobials. Adults with CF are also more prone to fungal sensitization when compared to
      non-CF patients as well as having higher rates of allergic rhinitis and atopy. In a
      retrospective study performed at our center, we found that children with intermittent or
      chronic fungal infections experienced more rapid decline in lung function compared to those
      without fungal infections regardless of ABPA status (see preliminary data). Understanding
      whether fungal infections are driven by an allergic (Th2) inflammatory process may alter
      treatment approaches by utilizing steroids and antifungal therapies more readily in patients
      with fungal infection to combat lung function decline. Limited studies have investigated the
      frequency of allergic sensitization to fungal pathogens in individuals with CF, the frequency
      of allergic sensitization in the pediatric CF population in general, and the unique
      inflammatory profiles and phenotypes of CF fungal infections, both in the sputum and the
      serum.

      Hypothesis: We hypothesize that children with CF and fungal infections without ABPA will have
      elevated allergic inflammatory profiles and increased sensitization to fungal elements
      compared to those without fungal infection.

      Specific Aim 1: Compare Th2 inflammation in patients with and without fungal infections in
      patients with CF and to those with ABPA.

        -  Approach: We will obtain serum and sputum samples from 25 patients with either (1)
           fungal infection without ABPA, n=10 (defined as ≥ two positive fungal cultures in prior
           18 months), (2) no fungal infection, n=10, and (3) ABPA, n=5, and measure specific
           sputum and serum cytokine measurements to evaluate Th2 and Th1 inflammatory pathways.

        -  Biomarkers measured: Eosinophilic cationic protein (ECP), Interleukin-4 (IL4),
           Interleukin-5 (IL5), Interleukin-10 (IL10), Interleukin-13 (IL13), and eosinophil count
           in both serum and sputum.

        -  Expected outcome: Individuals with fungal infection without APBA will have elevated Th2
           markers of inflammation compared to those with no fungal infection. We will also compare
           to those with ABPA as a separate control group. We will also measure Th1 markers to be
           used as a reference to previously established inflammatory profiles seen in CF, seeing
           if those with fungal disease deviate towards a more Th2 driven process.

      Specific Aim 2: Investigate allergic sensitization to fungal elements in patients with CF
      fungal infection without ABPA compared to those without fungal infection and to those with
      ABPA.

        -  Approach: We will measure total IgE and serum ImmunoCAP testing of specific IgE levels
           to fungal proteins of various species (Aspergillus, Candida, etc). to determine fungal
           sensitization. We will also survey patients regarding environmental exposures to explore
           relationships with allergic sensitization.

        -  Expected outcome: Individuals with fungal infection without ABPA will be more likely to
           show allergic sensitization to fungal elements when compared to those with no fungal
           infection.

      The results of this study will help characterize the inflammatory profile associated with CF
      fungal infections contributing to the understanding of both the infectious and allergic
      nature of disease in the CF population. From this, the contribution to both the
      pathophysiology and clinical characteristics of CF fungal infections will serve as a step
      towards understanding management options, care guidelines, and disease progression for this
      unique set of hard to treat organisms.

      Recruitment: We propose to recruit 25 patients with CF aged between 8 and 25 years who agree
      to participate in this cross-sectional study looking at the immune system characteristics of
      fungal infection and ABPA. We plan to screen individuals coming to their routine CF clinic
      and approach them regarding their interest in participating in this study. From this, we will
      explain the concept, hypothesis, and procedures involved with intent to schedule them for a
      research visit.

      Patient Selection: Patients will be recruited from the CF Center at CHCO by study
      investigators or qualified research coordinators at the time of a routine clinic visit.

      Study Visit: We plan to prospectively recruit 25 subjects with CF during a period of clinical
      stability. Subjects will have one research clinic visit that will coincide with their clinic
      visit at CHCO Pulmonary Clinic facilities. The following diagnostic information will be
      entered onto Case Report Forms: demographic information, diagnostic history and mutations,
      CF-related co-morbidities, historic microbiology results including fungal culture results,
      medications including modulator therapy and long-term antibiotic regimens, previous allergy
      testing, diagnostic criteria for ABPA (if applicable). We will also utilize historical
      clinical data from the medical record to establish other co-morbidities, lung function trends
      and baseline, history of other bacterial infections, history of allergy diagnoses, and other
      pertinent medical history and diagnostic testing (ie previous CT scan results, previous blood
      work, etc.). The following evaluations will be performed :

        -  Historical data in the medical record. Examples include Co-morbid diagnoses related to
           CF (such as but not limited to CF related diabetes, CF liver disease, asthma, etc),
           previous blood work (such as but not limited to serum IgE levels, previous allergy
           testing, bronchoscopy data and lavage studies, routine and urgent/admission CF labs,
           etc), previous spirometery and lung function data, previous nutritional and growth data
           (BMI, vitamin levels, etc), previous microbiology and culture data, etc.

        -  BMI measurements obtained from regular CF clinic visit

        -  Height and weight to be obtained and subsequently calculated.

        -  Pulmonary function testing obtained from regular CF clinic visit. Spirometry will be
           performed according to American Thoracic Society criteria, while absolute values will be
           converted to percent predicted using the Global Lung Function initiative reference
           equations34.

        -  Sputum collection. Spontaneously expectorated sputum will be used as possible.This will
           be collected at home by the patient following a routine respiratory airway clearance
           regimen within 12 hours of clinic visit. The sample will be placed in a mailed specimen
           cup and placed on ice and brought to the clinic visit. If sputum is not able to be
           expectorated prior to visit, we will attempt to utilize remaining sputum expectorated
           that is not used for clinical needs for further analysis and storage. Sputum may be
           collected by sputum induction according to the current CFF Therapeutics Development
           Network standard operating procedure if 1) unable to expectorate, (2) patient meets
           clinical criteria for sputum induction and (3) clinic is able to perform research
           induced sputum based on current COVID-19 guidelines to ensure safety of team member and
           adequate PPE supply.

      For safety reasons, the induction procedures will only be performed for subjects who meet the
      following criteria on the day of the induction: FEV1 ≥ 30% predicted, No history of > 5 mL
      hemoptysis within 48 hours prior to the visit, Able to tolerate the sputum induction
      procedure. Of note, there is little significant difference in specimen quality for analysis
      between expectorated and induced sputum. Markers to be tested as previously described above.

        -  Environmental fungal exposure questionnaire. Will be performed prior to finish of clinic
           visit. This questionnaire in entirety is a validated questionnaire used by Dr. Andy Liu.
           Given time constraints for study participants, we are using a modified questionnaire
           focused on questions of interested to this study (e.g. pertaining to fungal exposure).
           This has not been validated but may provide important information in this pilot study
           for future research

        -  Serum collection. Peripheral venous blood draw will be performed by certified individual
           using appropriate sterile technique by the CTRC. Samples will be labeled per research
           protocol standards. Markers to be tested described above.

             -  All sputum samples to be banked and saved for potential microbiome, mycobiome and
                transcriptome analysis, assessing gene expressions unique to various inflammatory
                pathways.

      Sample Size Estimates: Power and sample size for the study proposal is fixed due to the
      expected number of eligible patients to be recruited into this pilot study during the study
      window. Based on preliminary data and the described definitions of types of infection,
      investigators anticipate that over a 1-year recruitment window they will be able to enroll
      approximately 10 individuals with no fungal infection, 10 patients with a fungal infection
      but not ABPA and 5 with ABPA. The primary analysis plan focuses on the description and
      comparison of key plasma and sputum measures described in Table 3. Power analysis provides
      the detectable effect sizes when comparing the control arm (no fungal infection) to either
      the non-ABPA group or the ABPA group. Calculations are based on a power of 80% and Type I
      error rate of 0.05 for two-sided two-sample equal-variance t-test conducted in PASS version
      15 statistical software (2). Group sample sizes of 10 and 5 in the fungal infection groups
      achieve 80% power to reject the null hypothesis of zero effect size when the population
      effect size is 1.36 and 1.66 respectively. Thus, the study is powered at 80% to detect a
      difference in the mean markers to be measured greater than 1.66 and 1.32 standard deviations.
      Given limited data in the literature regarding Th2 markers in CF, we are basing these
      calculations off of deviations from a mean for the multiple Th2 markers we are testing.

      Data Collection and Storage: All subjects will be de-identified upon study sample collection
      and stored with a master key. There will be limited access to this information with the PI
      and only essential research staff able to monitor and view the data. All hardcopy source
      documents will be kept in a locked file cabinet in the CF research team's storage facilities.
      Additionally, to further ensure data integrity, data for this study will be stored in
      Research Electronic Data Capture system (REDCap), which will allow limited access to only
      essential personal. REDCap enables in-line validation to minimize transcription errors and
      provides real-time notifications of data submission and allows immediate central monitoring
      and feedback. Access to data requires an encrypted secure socket layer (SSL) connection and
      changes are logged by user ID, time stamp and project. Databases are backed up frequently.
observational model: Cohort
time perspective: Cross-Sectional
measure: Difference in Th2 Sputum Markers
time frame: Day 1
description: Difference in sputum Th2 biomarkers (ECP, IL4, IL5, IL10, IL13, and eosinophil count) in patients with CF with fungal infection with expected elevation of sputum Th2 biomarkers in patients with CF and ABPA compared to those without fungal infection and without ABPA.
measure: Other markers of fungal inflammation and allergic reaction in patients with CF
time frame: Day 1
description: Serum Th2 biomarkers in patients with fungal infection and ABPA (Table 3).
Serum Th1 biomarkers in patients with fungal infection and ABPA (Table 3).
Serum sensitization markers to fungal allergens in patients with fungal infection and ABPA (Table 4).
Baseline and historic lung function, historical comorbid diagnoses and BMI measurements in patients with fungal infection and ABPA.
Environmental factors that are possibly related to fungal infection and ABPA in patients with CF.
Immune profile: A profile of each group will be based upon their findings of each set of biomarkers: Th1, Th2, mold allergy panel, and systemic markers of inflammation. Based upon findings in each of these categories (elevated, depressed), we will be able to formulate a profile based upon the type of marker/inflammatory pathway.
measure: Biobanking of specimens
time frame: Day 1
description: Banking of both sputum and serum to potentially utilize microbiome and transcriptome techniques for further immunotyping and infection characterization.
arm group label: Fungal Infection Group
description: Have had a fungal species isolated from sputum and/or BAL culture on >= 2 separate occasions in the 18 months preceding study visit and do not have a diagnosis of ABPA (N=10).
arm group label: Control Group
description: Have never previously isolated fungus from sputum, BAL, or OP swab (N=10).
arm group label: ABPA Group
description: Previous diagnosis of ABPA as defined by CFF guidelines, regardless of the amount of fungal infection or history thereof.
• ABPA Minimum diagnostic criteria per CFF: Acute or subacute deterioration, total serum IgE > 500 IU per mL, immediate cutaneous reactivity to Aspergillus or in vitro IgE antibody to A. fumigatus, and either a new or recent chest imaging change that has not responded to antibiotics and standard physiotherapy OR precipitin to A. fumigatus or IgG antibody to A. fumigatus1 (N=5). Culture positive sputum is not required for ABPA diagnosis and is not taken into account for the diagnosis per CFF guidelines.
Sputum and serum from subjects
study pop: 
sampling method: Non-Probability Sample
criteria: 
gender: All
minimum age: 8 Years
maximum age: 25 Years
last name: Thomas S Poore, MD
role: Principal Investigator
affiliation: University of Colorado, Denver
facility: 
country: United States
responsible party type: Principal Investigator
investigator affiliation: University of Alabama at Birmingham
investigator full name: Thomas Spencer Poore
investigator title: Assistant Professor
mesh term: Infections
mesh term: Communicable Diseases
mesh term: Mycoses
mesh term: Aspergillosis
mesh term: Pulmonary Aspergillosis
mesh term: Aspergillosis, Allergic Bronchopulmonary
mesh term: Cystic Fibrosis
mesh term: Fibrosis
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