Discussion:
According to our results, we observed no significant difference before and after transition for the main clinical prognosis criteria: pulmonary function, nutritional status, pulmonary colonization, hospitalizations and visits, and antibiotic courses.
The literature regarding transition in CF is focused on its perception by patients themselves and by members of the team and revealed that patients did not feel sufficiently empowered or prepared to transition (10–12). Previous articles tried to define a program for the transition process; it appeared to be difficult because each patient had different needs and did not feel ready at the same time (13). Patients’ and caregivers’ teams thought that transfer was more difficult when the preparation was not sufficient, particularly with patients’ reluctance, lack of maturity or severe condition. According to the authors, a successful transition relies on a progressive process that includes patient empowerment.
In Lyon, such a procedure has been set up since 2006 (4) and currently seems to be effective, with stable clinical and microbiological settings all along the transfer process. No patient was lost to follow-up despite their youth. Our article focused on objective data that ensure that transition is successful.
A similar study was conducted in Paris and reported that transferring from a pediatric center to an adult center after a special preparation avoids a negative impact on respiratory function or on BMI evolution just after transition (14). It showed that a well-prepared transition from a pediatric center to an adult center for CF care was crucial. However, this study was published more than ten years ago, and transfer occurred in older patients.
Focusing on Europe, in Germany (15), adult CF patients are often followed in pediatric wards. In this country, short-term programs of transition are under process, with encouraging results in clinical and microbiological features, but they are not yet generalized. Welsner and al described a transition program for 39 German patients and showed that this process was linked to stability of respiratory function, BMI and microbiological data and to an increase of outpatient’s consultation following transfer. In Denmark, Skov and al described transition in 40 patients, with no impact on respiratory function, BMI or quality of life (16).
A Belgian study showed that transition in cystic fibrosis is linked to worsening of FEV and FVC and increasing of Pseudomonas aeruginosacolonization, which highlights the fragility of patients during this period and enhances the importance of a transition program (17).
In North America, currently, some CF patients remain in pediatric centers for CF, but some encouraging data have shown the benefits of transfer on respiratory function (18). An American retrospective study demonstrated that patients transferring from a pediatric center to an adult center had a trend not to worsen their FEV versus patients remaining in pediatric centers (18). In both, the transfer process was followed by increasing numbers of outpatient consultations and of respiratory exams, perhaps because of anxiety in reaction to the transfer (14,18). In our study, outpatient consultations were not more frequent after transfer.
In Canada, a transition process has existed in a few hospitals for decades; its impact has been evaluated only on subjective data and showed improvement of quality of life for adults undergoing transition to an adult center (5).
Adolescence and early adulthood are difficult periods in a lifetime for people suffering from chronic diseases and are often linked to a worsening of health conditions (3). As such, patients with CF have to be managed in a formalized transition program to prevent such issues. One of the strengths of our study is that the totality of the 97 patients completed the entire follow-up period, and all participated in the same standardized transition program, with the use of common tools in both centers (informatics files and medical records) and well-defined protocols of care. Furthermore, our evaluation of transition included several objective criteria all along the transition process. Our study shows some limitations: it was a monocentric study, and we focused on objective parameters, without satisfaction evaluations of the transition process for the patients or caregivers.
Our ten-year experience of a formalized program for transition in CF allows for patients to maintain a stable medical situation over this risky period of transition.
Recently, major innovations for CF patient treatment were worked out, particularly CF triple therapy, with impressive results on FEV on 2019 (19,20), which may revolutionize the CF course.
It appears essential to associate these therapeutic innovations with strong transition programs between pediatric and adult centers for CF.
Abbreviations:
ABPA: Allergic bronchopulmonary aspergillosis
AF: Aspergillus fumigatus
BC: Burkholderia cepacia
BMI: Body mass index
CF: Cystic fibrosis
CFTR: Cystic fibrosis transmembrane conductance regulator
CRCM: Centre de Ressources et de Compétences pour la Mucoviscidose
FEV: Forced expiratory volume
MRPA: Multidrug-resistant Pseudomonas aeruginosa
MRSA: Methicillin-resistant Staphylococcus aureus
MSPA: Multisensitive Pseudomonas aeruginosa
MSSA: Methicillin-susceptible Staphylococcus aureus
SM: Stenotrophomonas maltophilia
NTM: Nontuberculosis Mycobacterium
PA: Pseudomonas aeruginosa
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