Cystic fibrosis (CF) is an inborn, hereditary disease, due to mutations in the gene for a cAMP-activated chloride (Cl-) channel, the cystic fibrosis transmembrane conductance regulator (CFTR). As a result of impaired ion and water transport,the airway mucus is abnormally viscous, which leads to bacterial colonization.Recurrent infections and inflammation result in obstructive pulmonary disease.Similar changes in the pancreas lead to pancreatic insufficiency.Several compounds have been tested to improve transepithelial ion transport in CF patients, either via activation of the mutant CFTR, or via stimulation of alternative chloride channels. The main purpose of this thesis was to find substances that might correct the defective ion transport in epithelial cells in CFand could be useful for the pharmacological treatment of CF patients. Long-term treatment with the macrolide antibiotic azithromycin (AZM)improved clinical parameters and lung function in CF patients and increased Cl- transport in CF bronchial epithelial cells (CFBE) (Paper I); although mRNA expression of the CFTR gene remained unchanged.In contrast, pre-exposure to the mucolytic antioxidant N-acetylcysteine (NAC) increased CFTR protein expression and was associated with increased Cl- efflux from CFBE cells (Paper II). Clinical trials of this substance might be warranted. Duramycin has been the subject of clinical trials that finished in June2009. Up till now, no results from this study are available. The effect of this substance on Cl- efflux from three CF and three non-CF cell lines (Paper III) was disappointing. An effect was found only in CFBE cells, the effect was minimal, occurred in a narrow concentration range, and was not associated with an increase in the intracellular calcium concentration [Ca2+]i. The fact that NO-donors stimulated Cl- efflux from CFBE cells (but did notchange [Ca2+]i) after several hours of preincubation suggests that these substances may be a potentially interesting group of compounds for the treatment of CF (Paper IV). A model for the effect of NO-donors on Cl- efflux is presented. / Cystisk fibros (CF) är en medfödd, ärftlig, sjukdom, som förorsakas av en mutation i en gen som innehåller koden för en kloridkanal som aktiveras av cykliskt AMP (cystic fibrosis transmembrane conductance regulator, CFTR). Som en följd av otillräcklig transport av joner och vatten är slemmet i luftvägarna onormalt segt, vilket leder till att det koloniseras av bakterier. Upprepade infektioneroch inflammation av luftvägarna leder slutligen till obstruktiv lungsjukdom.Liknande förändringar i bukspottkörteln leder till att också detta organ inte fungerar. Flera kemiska ämnen har testats för sin förmåga att förbättra jontransporten över epitelet hos CF-patienter. Detta skulle kunna göras antingen genom aktivering av det muterade CFTR-proteinet, eller genom stimulering av alternativa kloridkanaler. Huvudsyftet med den forskning som beskrivs i denna avhandling var att hitta kemiska substanser som skulle kunna korrigera den defekta jontransporten i epitelceller hos CF-patienter, och därför vara nyttiga för behandlingen av patienterna. Behandling under längre tid med azithromycin (AZM), ett makrolidantibiotikum,förbättrade CF-patienternas kliniska status och lungfunktion,samt ökade kloridutflödet från CF bronkialepitelceller (CFBE-celler) (Arbete I).Däremot ändrades inte uttrycket av mRNA för CFTR-genen. I kontrast till detta ökade uttrycket av CFTR-proteinet om CFBE-cellerna utsattes för den slemlösande anti-oxidanten N-acetylcystein (NAC), vilket ledde till ökat kloridutflöde från denna cellinje (Arbete II). Det vore rimligt att utföra kliniska prövningar av detta ämne. Duramycin har testats i kliniska prov som slutade i juni 2009, men några resultatfrån dessa prov har inte offentliggjorts än. Effekten av detta ämne på kloridutflödet från tre CF-cellinjer och tre icke-CF cellinjer (Arbete III) var en besvikelse. Duramycin hade endast effekt på CFBE-celler, effekten var mycket liten, förekom endast i ett litet koncentrationsområde av duramycin, och var inte kopplad till en ökning av den intracellulära kalciumkoncentrationen [Ca2+]i. Att ämnen som avger kväveoxid (NO) stimulerade kloridutflödet från CFceller (men inte påverkade [Ca2+]i) efter några timmar, visar att denna grupp av ämnen kan vara potentiellt intressant för behandlingen av CF (arbete IV). En modell för effekten av NO på kloridtransporten i CF-celler presenteras.

Introduction : La fibrose kystique (FK) est une maladie génétique mortelle qui touche principalement les poumons et l’appareil digestif. Elle est causée par des mutations sur le gène codant la protéine du CFTR, un canal chlore exprimé à la surface des organes à sécrétions exocrines. Les fonctions principales du CFTR sont les suivantes: 1) la régulation de l’homéostasie ionique des sécrétions; 2) le maintien de la fluidité des sécrétions et; 3) le transport du glutathion. Le dysfonctionnement de la protéine du CFTR rend les sécrétions visqueuses et épaisses, avec des phénomènes obstructifs qui sont responsables de l’apparition de fibrose au sein des divers organes. Dans le poumon, l’accumulation du mucus épais rend difficile l’élimination des bactéries inhalées, ces dernières établissent alors des cycles d’infection qui endommagent les tissus pulmonaires à travers des processus inflammatoires. Dans le tube digestif, le mucus épais entrave l’absorption d’une quantité suffisante d’éléments nutritifs incluant les principaux antioxydants. L’infection et l’inflammation des poumons favorisent l’apparition d’un stress oxydant qui détruit davantage le tissu pulmonaire. Le déficit en glutathion, probablement lié au dysfonctionnement de la proteine du CFTR, et la malabsorption des antioxydants favorisent l’augmentation du stress oxydant. Une augmentation du stress oxydant a été démontrée au cours du diabète et les produits dérivés du stress oxydant ont été mis en évidence dans la pathogenèse des complications associées au diabète. Une augmentation du stress oxydant a également été montrée durant la FK, mais sans pour autant expliquer la survenue du diabète secondaire à la FK dont la prévalence augmente sans cesse. Objectifs : Notre étude consiste à évaluer l’impact du stress oxydant dans les anomalies du métabolisme du glucose durant la FK, et à étudier son rôle dans les mécanismes de sécrétion d’insuline induite par le glucose. Pour ce faire, nous avons déterminé l’impact de la peroxydation lipidique sur la tolérance au glucose et la défense antioxydante globale, in vivo, chez des patients FK présentant une altération du métabolisme du glucose. De plus, nous avons évalué le rôle du stress oxydatif sur la synthèse et la sécrétion d’insuline, in vitro, dans les cellules pancréatiques βTC-tet. Résultats : Dans l’étude in vivo, nous avons démontré que l’intolérance au glucose et le diabète étaient associés à une augmentation de la peroxydation lipidique, traduite par la hausse des niveaux sanguins de 4-hydroxynonenal lié aux protéines (HNE-P). La défense antioxydante évaluée par la mesure du glutathion sanguin démontre que les niveaux de glutathion oxydé restent également élevés avec l’intolérance au glucose. Dans l’étude in vitro, nos résultats ont mis en évidence que l’exposition de la cellule βTC-tet au stress oxydant: 1) induit un processus de peroxydation lipidique; 2) augmente la sécrétion basale d’insuline; 3) diminue la réponse de la sécrétion d’insuline induite par le glucose; et 4) n’affecte que légèrement la synthèse de novo de l’insuline. Nous avons aussi démontré que les cellules pancréatiques βTC-tet résistaient au stress oxydant en augmentant leur synthèse en glutathion tandis que la présence d’un antioxydant exogène pouvait restaurer la fonction sécrétoire de ces cellules. Conclusion : Le stress oxydant affecte le fonctionnement de la cellule pancréatique β de plusieurs manières : 1) il inhibe le métabolisme du glucose dont les dérivés sont nécessaires à la sécrétion d’insuline; 2) il active la voie de signalisation impliquant les gènes pro-inflammatoires et; 3) il affecte l’intégrité membranaire en induisant le processus de peroxydation lipidique. / Introduction: Cystic fibrosis (CF) is the most prevalent lethal genetic disorder affecting mostly lungs and the gastro-intestinal tract. CF is caused by mutations in the gene encoding the CFTR protein, a chloride channel expressed in organs with exocrine secretions. The main functions of the CFTR channel are the following: 1) regulation of electrolyte composition of secretions; 2) maintenance of fluid secretions and; 3) transport of glutathione. The CFTR protein dysfunction leads to thick and viscous secretions with obstructive phenomena responsible for fibrosis occurence in various organs. In the lungs, accumulation of the thick mucus reduces their capacity to eliminate inhaled bacteria responsible for repeated infections and pulmonary tissue damage through inflammatory processes. In the gastro-intestinal tract, the thicknened micus leads to nutritive elements and the major antioxidants malabsorption. Increased oxidative stress has been associated with the onset of diabetes and oxidative stress by-products have been involved in the pathogenesis of diabetic complications. Increased oxidative stress has also been shown in CF but the relationship between oxidative stress and the occurrence of CF-related diabetes (CFRD) remains unclear. Objectives: Our study aims to investigate the role of oxidative stress in the impaired glucose metabolism in CF patients and its relation with the altered glucose-stimulated insulin secretion process. We first determined the impact of lipid peroxidation on glucose tolerance and the antioxidant status in CF patients with altered glucose tolerance. Secondly, we evaluated the role of oxidative stress on insulin synthesis and secretion in the murine pancreatic β-cell line βTC-tet. Results: In CF patients, we demonstrated that conditions of glucose intolerance and diabetes are associated with increased lipid peroxidation as seen with increased blood levels of 4-hydroxynonenal bound to proteins (HNE-P). The antioxidant status evaluated with blood levels of glutathione showed a strong correlation between levels of oxidized glutathione and glucose intolerance. Acute exposure of βTC-tet to oxidative stress led to: 1) increased lipid peroxidation marker levels; 2) increased insulin release in basal conditions; 3) altered glucose-stimulated insulin secretion process and; 4) no effect on the insulin synthessis pathway. We also demonstrated that pancreatic βTC-tet cells can fight against oxidative stress by upregulating their glutathione synthesis whereas the presence of an exogenous antioxidant can restore their secretory function. Conclusion: Oxidative stress can induce β-cell dysfunction through many pathways: 1) it inhibits the glucose metabolism and its by-products which are required for insulin secretion, 2) it activates the signalling pathway involving the pro-inflammatory genes and; 3) it damages the cell structure by inducting the lipid peroxidation process.

Cystic fibrosis is caused primarily by deletion of Phe508. An exciting discovery was that CFTR’s sister protein, the P-glycoprotein (P-gp) containing the equivalent mutation (ΔY490), could be repaired by a drug-rescue approach. Drug substrates showed specificity, and their mechanism involves direct binding to the transmembrane domains (TMDs) since arginine suppressor mutations were identified in TMDs that mimicked drug-rescue to promote maturation. We tested the possibility of rescuing CFTR processing mutants with a drug-rescue approach. 1) Arginine mutagenesis was performed on TM6, 8, and 12. 2) Correctors were tested for specificity. 3) Truncation mutants were used to map the VX-809 rescue site. Correctors 5a, 5c, and VX-809 were specific for CFTR. VX-809 appeared to specifically rescue CFTR by stabilizing TMD1. Therefore, the TMDs are potential targets to rescue CFTR. Rescue of P-gp and CFTR appeared to occur by different mechanisms since no arginine suppressor mutations were identified in CFTR.

Cystic fibrosis is caused primarily by deletion of Phe508. An exciting discovery was that CFTR’s sister protein, the P-glycoprotein (P-gp) containing the equivalent mutation (ΔY490), could be repaired by a drug-rescue approach. Drug substrates showed specificity, and their mechanism involves direct binding to the transmembrane domains (TMDs) since arginine suppressor mutations were identified in TMDs that mimicked drug-rescue to promote maturation. We tested the possibility of rescuing CFTR processing mutants with a drug-rescue approach. 1) Arginine mutagenesis was performed on TM6, 8, and 12. 2) Correctors were tested for specificity. 3) Truncation mutants were used to map the VX-809 rescue site. Correctors 5a, 5c, and VX-809 were specific for CFTR. VX-809 appeared to specifically rescue CFTR by stabilizing TMD1. Therefore, the TMDs are potential targets to rescue CFTR. Rescue of P-gp and CFTR appeared to occur by different mechanisms since no arginine suppressor mutations were identified in CFTR.

Burkholderia cepacia complex (Bcc) species are opportunistic pathogens in patients with cystic fibrosis (CF), which are able to cause lethal infections. The Bcc are inherently resistant to most classes of antibiotics, which makes successful treatment problematic. Lipid A (also known as endotoxin), the hydrophobic anchor of lipopolysaccaride (LPS), is the bio-active component of LPS. One of several unique characteristics of the lipid A of the Bcc, is the permanent attachment of 4-amino-4-deoxy-L-arabinose (L-Ara4N) to the lipid A molecule. Also, the genes involved in L-Ara4N biosynthesis are necessary for viability in B. cenocepacia. Here we present research on lipid A biosynthesis, modi cation, and transport in the Bcc and highlight promising antimicrobial targets. The synthetic antibiotic CHIR-090 is an inhibitor of LpxC, an enzyme involved in the lipid A biosynthetic pathway. I investigated the activity of CHIR-090 against the Bcc and found that sensitivity to this antibiotic was both species- and strain-specific. CHIR-090 displayed MICs between 0.1 and 12.5 μg/ml against a panel of B. multivorans, the most prevalent Burkholderia species in CF. The species- and strain-specific sensitivity towards CHIR-090 was further explored and a strong correlation was found between the presence of a unique open reading frame, named LpxC2, in resistant species. To address the problem of multiple drug-resistance of the Bcc, we investigated the activity of the pyridoxal 50-phosphate (PLP)-dependent enzyme inhibitor cycloserine (CS) against the Bcc. CS is used as a second line of defense against M. tuberculosis. The activity of the D-enantiomer of CS (DCS) against the Bcc was tested and displayed MICs between 2 and 128 μg/ml and acted bactericidal towards the Bcc. Additionally, DCS inhibition of recombinant ArnB from B. cenocepacia J2315, a PLP-dependent enzyme necessary for viability in the Bcc, was studied. ArnB was inhibited reversibly by DCS. ArnB was further explored as a promising drug-target in the Bcc, but only CS has been identified as an inhibitor so far. In this thesis it was attempted to find the reason why is L-Ara4N modification of lipid A necessary for viability in B. cenocepacia. Therefore, two proteins were characterised, which are involved in lipid A transport: LptA, the periplasmic lipid A binding protein, and LptB, the cytoplasmic ATP-ase. LptA was found to be able to bind both modified and unmodified lipid A in vitro and therefore is not L-Ara4N specific. Furthermore, LptA could bind deep-rough-, rough-, and smooth- LPS, similar to that described for Escherichia coli LptA. The kinetic parameters of LptB were determined in vitro (kcat = 5.71 min-1 and KM = 0.88 mM), and were comparable to E. coli LptB. The ATP-ase activity of LptB was not influenced by the presence of any forms of LPS (modified or non-modified). Therefore, we concluded that both B. cenocepacia J2315 LptA and LptB are not L-Ara4N specific.

Azithromycin improves clinical outcomes in patients with cystic fibrosis (CF), specifically in patients infected with Pseudomonas aeruginosa. Azithromycin shifts macrophage programming away from a pro-inflammatory classical (M1) phenotype, and towards an anti-inflammatory alternative (M2) phenotype; however, little is known about this mechanism, nor of its impact upon immune response to pulmonary infection. We set out to determine the mechanism by which azithromycin is able to alter macrophage phenotype, and assess the effect of azithromycin induced macrophage polarization on inflammation during pulmonary infections. Utilizing macrophage cell culture, we found that azithromycin increased IKKβ, a signaling molecule in the NFκB pathway, which likely is altering macrophage programming. Using a Pseudomonas infection model in mice that lack physiologic alternative macrophage activation, we showed that azithromycin’s ability to alter macrophage function and decrease lung damage was independent of interleukin control of macrophage programming. Azithromycin increased fibrotic protein production both in vivo and in vitro, but blunted immune-driven fibrotic damage. We extended our study to patients with CF, describing gene expression in macrophages isolated from sputum samples. We found markers consistent with a shift toward M2 polarization in these patients. These data suggest potential mechanisms by which azithromycin benefits patients with CF.

In der vorliegenden medizinischen Promotionsschrift werden verschiedene nicht-invasive Untersuchungsverfahren bei erwachsenen Patienten mit Zystischer Fibrose (CF) zur Detektion einer Leberbeteiligung (CFLD) evaluiert. Das diagnostische Standard-verfahren bei vielen Hepatopathien, die Leberbiopsie, ist auf Grund der fokalen Manifestation der CFLD und der häufigen pulmonalen Begleiterkrankung bei CF nicht Bestandteil der Routinediagnostik. CF- Patienten werden daher im Rahmen der vorliegenden Studie mittels konventionellen Ultraschalls, Acoustic Radiation Force Impulse (ARFI) - Imagings, Transienter Elastographie (TE) und verschiedener Fibrosescores untersucht. Ferner wird die Eignung der elastographischen Methoden als Verlaufsparameter bei einem Teil der Studienkohorte evaluiert. Ziel ist die Bewertung des diagnostischen Nutzens der angewandten Untersuchungsmethoden bezüglich der Differenzierung zwischen CF-Patienten ohne Leberbeteiligung, CFLD und CFLD-induzierter Zirrhose. Lebergesunde Probanden und Patienten mit ethyltoxischer Leberzirrhose dienen als Kontrollgruppen. Die Ergebnisse dieser wissenschaftlichen Arbeit zeigen, dass die elastographische Untersuchung der Leber bei erwachsenen CF- Patienten, als nicht-invasives Verfahren im Rahmen der Routinediagnostik zur Detektion einer CFLD-induzierten Zirrhose, ergänzend genutzt werden kann. Für die Beurteilung des klinischen Nutzens als Verlaufsparameter sind weitere Studien notwendig.

This dissertation involved linking a clinical cystic fibrosis (CF) data registry with administrative databases to evaluate clinical, demographic, and geographical predictors of hospitalization in CF patients living in Ontario over a 10 year period. In addition, this work assessed the ability of administrative data to identify individuals with CF using the clinical registry as the reference standard. Sex was an independent predictor of hospitalization rates for individuals with CF. Females had a significantly higher hospitalization rate compared to males even after adjusting for important clinical factors suggesting that this finding is not simply due to worse CF disease. In those between 7 and 19 years of age, the adjusted hospitalization rate was 38% higher in females (rate ratio[RR] 1.38, 95% confidence interval [CI] 1.11-1.73). Similarly in those over the age of 19, females had a 30% higher hospitalization rate compared to males (RR 1.30, 95% CI 1.06-1.59). Other significant predictors associated with higher hospitalization rates in both age groups were lower lung function, worse nutritional status, pancreatic insufficiency, and the presence of CF-related diabetes. The presence of Burkholderia cepacia complex in the sputum was a significant predictor in those over the age of 19 years (RR 1.54, 95% CI 1.26-1.89). Distance to CF centre, community size and socioeconomic status were not significant predictors of hospitalization rates in either age group. There was no significant trend in hospitalization rates over time once rates were adjusted for markers of disease severity (p=0.08). Comparing administrative data with the CF registry data, administrative data captured hospitalizations more comprehensively. Despite CF being a specific diagnosis, health administrative databases alone were insufficient to reliably and accurately identify individuals with CF unless they had been hospitalized. The reason for the gender disparity seen within this dissertation is likely multifactorial. There may be differences in outpatient management between the sexes, hormonal influences may modulate disease severity causing higher hospitalization rates, and patient and provider-level influences may affect the decision to hospitalize a patient. Further research is needed in this area to elucidate the factors contributing to this gender gap.

Cystic Fibrosis (CF) is an autosomal recessive disease that arises from mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. The deletion of phenylalanine-508 (ΔF508-CFTR) is the most prevalent CF mutation and results in a misfolded protein that fails to exit the endoplasmic reticulum (ER). Previous studies demonstrated that mutation of a di-arginine based ER retention motif (R553AR555) in the first nucleotide binding domain (NBD1) rescues the trafficking defect of ΔF508-CFTR. We hypothesized that if the R553AR555 motif mediates retention of the ΔF508-CFTR protein, peptides that mimic this motif should antagonize mistrafficking mediated by aberrant exposure of the endogenous R553AR555 motif. We generated a peptide bearing the R553AR555 motif (CF-RXR) and conjugated it to the cell penetrating peptide Tat (CPP-CF-RXR) to facilitate intracellular delivery and investigated its efficacy in rescuing the mistrafficking and function of ΔF508-CFTR. Using a variety of biochemical and functional assays we demonstrate that the CPP-CF-RXR peptide is effective at increasing surface expression of ΔF508-CFTR in baby hamster kidney (BHK) and human embryonic kidney (HEK) cell lines. Furthermore, the increased surface expression is accompanied by an increase in its functional expression as a chloride channel. Using Ussing chamber assays, we demonstrate that the CPP-CF-RXR peptide improved ΔF508-CFTR channel function in respiratory epithelial tissues obtained from CF patients. Additionally, we investigated the effects of small molecules on mediating biosynthetic rescue of a ΔF508-CFTR construct bearing the additional mutations R553K and R555K (ΔFRK-CFTR) to inactivate the R553AR555 motif. Interestingly, mutation of the R553AR555 motif exerts an additive effect with correctors VRT-325 and Corrector 4a. Taken together, our data suggests that abnormal accessibility of the RXR motif present in NBD1 is a key determinant of the mistrafficking of the major CF causing mutant.

This thesis uses the International Classification of Functioning, Disability and Health (ICF) model (World Health Organisation, 2001) to explore the multidimensional presentation of strengths and problems in young people with cystic fibrosis (CF), firstly examining its theoretical “fit” to the health condition, and secondly using it to characterise the performance of those with CF. Few studies in the literature demonstrate such an holistic approach to the physiotherapy assessment and management of this population. It was expected that this description of performance would provide a framework for identifying key areas for physiotherapy exercise intervention. This then formed the basis for further studies to examine the effect of a targeted exercise program (compared to current exercise practice) on inpatient outcomes, as well as on outcomes of outpatient management. The position paper included provides theoretical support for the ICF model as an appropriate tool in the management of young people with CF. Building on this, Study 1 explored the practical utility of the ICF model for describing the presentation of young inpatients and outpatients with CF. Eighty-four participants with CF were recruited as a consecutive series who satisfied selection criteria to provide a cross-sectional view at younger (7-12 years, n=51) and older (13-17 years, n=33) ages. Musculoskeletal, respiratory and physiological measures represented the body structures and functions domain, the six-minute walk test and jump tests were included in the activities domain, and participation was described by the Cystic Fibrosis Questionnaire–Revised Version and Fels Physical Activity Questionnaire. Contextual factors were also considered (age, gender, inpatient/outpatient status). In this exploratory study, performance of this population was compared to normative data where available. Also, correlations between measures within and between ICF domains were examined as suggested by the model itself. Finally, effects of contextual factors on performance were investigated using univariate analysis of variance. This first study and the position paper support the ICF model as an effective tool for describing performance of young people with CF, and for investigating functional relationships within and between domains. Results showed significant differences in this population compared to normative data, and interrelationships were identified within and between ICF domains. Between inpatients and outpatients in the specified age groups, there was a statistically significant difference in means for a number of measures, whereby inpatients displayed consistently poorer mean scores than outpatients, with this effect significantly stronger in the older age group. The application of the ICF model was useful for highlighting areas to target in physiotherapy exercise intervention, and for substantiating selected measures to assess the program’s effectiveness across domains. Study 2 was a randomised controlled trial with blinded assessor, which investigated the effectiveness of a 10-14 day inpatient-based exercise program (the Cystic Fibrosis: Fitness Challenge) (CF:FC) tailored for young people with CF (7-17 years). The CF:FC program (n=15) included exercise strategies based on recommendations from previous work in the field, and from findings from Study 1. This program included a portable exercise package (FitKitTM) designed to be adaptable to limited space environments such as at the hospital bedside, important when inpatients with CF are isolated according to infection control procedures. Participants in the control program (n=16) received the current exercise practice provided for young people with CF at a tertiary hospital, which included mainly aerobic-type activities to affect airway clearance. Performance on study measures (scoped within the framework of the ICF model, presented in Study 1) were compared pre- and post-intervention (admission and completion of the inpatient exercise program) between the groups. This trial showed significant improvements for participants in both groups from admission to discharge for a range of measures, including respiratory function, muscle strength and quality of life measures. Participants in the intervention group showed significantly greater improvements for some measures, for example: ankle dorsiflexor strength, six-minute walk distance and perception of their respiratory status. The continuation of the intervention and control programs into the outpatient setting was the focus of Study 3. The FitKitTM was provided for the intervention group, incorporating strategies to enhance adherence including a physical activity log (PAL) and internet-based follow-up. The control home exercise program consisted of the current practice provided on discharge. Interestingly, the control group improved significantly in hip abductor strength and six-minute walk distance during the outpatient period, whereas the intervention group sustained the improvements gained in the inpatient period but generally showed no further significant improvement. When the change from inpatient admission to outpatient follow-up was considered, it was apparent that greater improvements during the inpatient period provided a ‘buffer’ to accommodate for possible deteriorations in function in the outpatient phase. Issues regarding adherence to exercise programs during the outpatient period are discussed. This thesis confirms the usefulness of the ICF model for describing young people with CF, guiding assessment and review processes to achieve comprehensive management, and strengthening the evidence-base for targeted physiotherapy exercise intervention. A novel, tailored exercise program is introduced which is effective during inpatient periods, and provides a maintenance effect during outpatient periods, but strategies to enhance adherence during outpatient periods require further investigation.