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Chen JY, Li S, Silva GL, Chandler JD, Prausnitz MR, Guglani L. Sweat induction using Pilocarpine microneedle patches for sweat testing in healthy adults. J Cyst Fibros 2024; 23:112-119. [PMID: 37236899 DOI: 10.1016/j.jcf.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND The sweat test using pilocarpine iontophoresis remains the gold standard for diagnosing cystic fibrosis, but access and reliability are limited by specialized equipment and insufficient sweat volume collected from infants and young children. These shortcomings lead to delayed diagnosis, limited point-of-care applications, and inadequate monitoring capabilities. METHODS We created a skin patch with dissolvable microneedles (MNs) containing pilocarpine that eliminates the equipment and complexity of iontophoresis. Upon pressing the patch to skin, the MNs dissolve in skin to release pilocarpine for sweat induction. We conducted a non-randomized pilot trial among healthy adults (clinicaltrials.gov, NCT04732195) with pilocarpine and placebo MN patches on one forearm and iontophoresis on the other forearm, followed by sweat collection using Macroduct collectors. Sweat output and sweat chloride concentration were measured. Subjects were monitored for discomfort and skin erythema. RESULTS Fifty paired sweat tests were conducted in 16 male and 34 female healthy adults. MN patches delivered similar amounts of pilocarpine into skin (1.1 ± 0.4 mg) and induced equivalent sweat output (41.2 ± 25.0 mg) compared to iontophoresis (1.2 ± 0.7 mg and 43.8 ± 32.3 mg respectively). Subjects tolerated the procedure well, with little or no pain, and only mild transient erythema. Sweat chloride concentration measurements in sweat induced by MN patches (31.2 ± 13.4 mmol/L) were higher compared to iontophoresis (24.0 ± 13.2 mmol/L). Possible physiological, methodological, and artifactual causes of this difference are discussed. CONCLUSIONS Pilocarpine MN patches present a promising alternative to iontophoresis to enable increased access to sweat testing for in-clinic and point-of-care applications.
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Affiliation(s)
- Jonathan Yuxuan Chen
- The Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, GA 30332, USA; Global Center for Medical Innovation, Atlanta, GA 30318, USA
| | - Song Li
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - George L Silva
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30332, USA; Center for CF & Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Joshua D Chandler
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30332, USA; Center for CF & Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Mark R Prausnitz
- The Wallace H. Coulter Department of Biomedical Engineering at Georgia Tech and Emory University, Georgia Institute of Technology, Atlanta, GA 30332, USA; School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA.
| | - Lokesh Guglani
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30332, USA; Center for CF & Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, GA 30322, USA.
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Li S, Hart K, Norton N, Ryan CA, Guglani L, Prausnitz MR. Administration of pilocarpine by microneedle patch as a novel method for cystic fibrosis sweat testing. Bioeng Transl Med 2021; 6:e10222. [PMID: 34589599 PMCID: PMC8459588 DOI: 10.1002/btm2.10222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 01/18/2023] Open
Abstract
The sweat test is the gold standard for the diagnosis of cystic fibrosis (CF). The test utilizes iontophoresis to administer pilocarpine to the skin to induce sweating for measurement of chloride concentration in sweat. However, the sweat test procedure needs to be conducted in an accredited lab with dedicated instrumentation, and it can lead to inadequate sweat samples being collected in newborn babies and young children due to variable sweat production with pilocarpine iontophoresis. We tested the feasibility of using microneedle (MN) patches as an alternative to iontophoresis to administer pilocarpine to induce sweating. Pilocarpine-loaded MN patches were developed. Both MN patches and iontophoresis were applied on horses to induce sweating. The sweat was collected to compare the sweat volume and chloride concentration. The patches contained an array of 100 MNs measuring 600 μm long that were made of water-soluble materials encapsulating pilocarpine nitrate. When manually pressed to the skin, the MN patches delivered >0.5 mg/cm2 pilocarpine, which was double that administered by iontophoresis. When administered to horses, MN patches generated the same volume of sweat when normalized to drug dose and more sweat when normalized to skin area compared to iontophoresis using a commercial device. Moreover, both MN patches and iontophoresis generated sweat with comparable chloride concentration. These results suggest that administration of pilocarpine by MN patches may provide a simpler and more-accessible alternative to iontophoresis for performing a sweat test for the diagnosis of CF.
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Affiliation(s)
- Song Li
- School of Chemical and Biomolecular EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
| | - Kelsey Hart
- Department of Large Animal MedicineUniversity of Georgia College of Veterinary MedicineAthensGeorgiaUSA
| | - Natalie Norton
- Department of Large Animal MedicineUniversity of Georgia College of Veterinary MedicineAthensGeorgiaUSA
| | - Clare A. Ryan
- Department of Large Animal MedicineUniversity of Georgia College of Veterinary MedicineAthensGeorgiaUSA
| | - Lokesh Guglani
- Center for Cystic Fibrosis and Airways Disease ResearchEmory University Department of Pediatrics and Children's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Mark R. Prausnitz
- School of Chemical and Biomolecular EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
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Shenoy A, Spyropoulos D, Peeke K, Smith D, Cellucci M, Chidekel A. Newborn Screening for Cystic Fibrosis: Infant and Laboratory Factors Affecting Successful Sweat Test Completion. Int J Neonatal Screen 2020; 7:ijns7010001. [PMID: 33375576 PMCID: PMC7838990 DOI: 10.3390/ijns7010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/16/2022] Open
Abstract
Newborn screening (NBS) for Cystic Fibrosis (CF) has revolutionized the diagnosis of this inherited disease. CF NBS goals are to identify, diagnose, and initiate early CF treatment to attain better health outcomes. Abnormal CF NBS infants require diagnostic analysis via sweat chloride testing (ST). During ST, insufficient sweat volume collection causes a "quantity not sufficient" (QNS) test result and may delay CF diagnosis. The CF Foundation recommends QNS rates <10% for infants <3 months, but many CF Centers experience difficulties meeting this standard. Our quality improvement (QI) study assessed infant and laboratory factors contributing to ST success and QNS rates from 2017-2019. Infants' day of life (DOL) at successful ST completion was analyzed according to infant factors (birth weight (BW), gestational age, ethnicity, and sex). Laboratory factors and procedures affecting ST outcomes were also reviewed. At our institution, BW and gestational age were the infant factors found to significantly affect DOL at ST completion. ST education, reduced number of laboratory technicians, and direct observation during ST completion also improved ST success rates. This study supports QI measures and partnerships between CF centers and laboratory staff to identify and improve ST QNS rates while sustaining practices to ensure timely CF diagnostic testing.
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Affiliation(s)
- Ambika Shenoy
- Division of Pulmonology, Nemours, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA; (D.S.); (K.P.); (A.C.)
- Correspondence: ; Tel.: +1-302-651-6400
| | - Dina Spyropoulos
- Division of Pulmonology, Nemours, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA; (D.S.); (K.P.); (A.C.)
| | - Kathleen Peeke
- Division of Pulmonology, Nemours, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA; (D.S.); (K.P.); (A.C.)
| | - Dawn Smith
- Division of Laboratory Medicine, Nemours, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA;
| | - Michael Cellucci
- State of Delaware Newborn Screening Program, 1600 Rockland Road, Wilmington, DE 19803, USA;
| | - Aaron Chidekel
- Division of Pulmonology, Nemours, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA; (D.S.); (K.P.); (A.C.)
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McColley SA, Elbert A, Wu R, Ren CL, Sontag MK, LeGrys VA. Quantity not sufficient rates and delays in sweat testing in US infants with cystic fibrosis. Pediatr Pulmonol 2020; 55:3053-3056. [PMID: 32797669 DOI: 10.1002/ppul.25027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Diagnostic sweat testing is required for infants with positive newborn-screening (NBS) tests for cystic fibrosis (CF). Infants have "quantity not sufficient" (QNS) sweat volumes more often than older children. A comprehensive study of QNS sweat volumes in infants has not previously been reported. METHODS We surveyed US CF Centers to obtain QNS rates in all infants who had sweat testing at under 14 days and under 3 months of age. We then calculated QNS rates reported to the Cystic Fibrosis Foundation Patient Registry (CFFPR) 2010-2018 in 10-day increments from 1 to 60 days of life. We compared QNS sweat test rates in preterm (<37-weeks gestational age) vs term infants. We assessed age at sweat test and proportion of infants who did not have a sweat test reported by 60 days of age. RESULTS Thirty-nine of 144 (27%) of CF Centers reported a mean QNS rate of 10.5% (range, 0-100) in infants 14-days-old or younger. CFFPR data showed the highest QNS rates in the youngest infants and in those born before 37 weeks of gestation. The median age at sweat testing decreased over time, but more than 22% of infants did not have a sweat test reported by 60 days. CONCLUSION Higher QNS rates are seen in the youngest infants with CF, but more than 80% of infants younger than 2 weeks of age have adequate sweat volumes. Sweat testing should not be delayed in infants with a positive CF NBS test.
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Affiliation(s)
- Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Runyu Wu
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Clement L Ren
- Department of Pediatrics, Riley Children's Hospital, Indiana University, Indianapolis, Indiana
| | - Marci K Sontag
- Center for Public Health Innovation, Littleton, Colorado.,Department of Epidemiology, University of Colorado, Denver
| | - Vicky A LeGrys
- Department of Allied Health Science, University of North Carolina, Chapel Hill, North Carolina
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5
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Barben J, Chudleigh J. Processing Newborn Bloodspot Screening Results for CF. Int J Neonatal Screen 2020; 6:25. [PMID: 33073022 PMCID: PMC7422987 DOI: 10.3390/ijns6020025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/23/2020] [Indexed: 12/17/2022] Open
Abstract
Every newborn bloodspot screening (NBS) result for cystic fibrosis (CF) consists of two parts: a screening part in the laboratory and a clinical part in a CF centre. When introducing an NBS programme, more attention is usually paid to the laboratory part, especially which algorithm is most suitable for the region or the country. However, the clinical part, how a positive screening result is processed, is often underestimated and can have great consequences for the affected child and their parents. A clear algorithm for the diagnostic part in CF centres is also important and influences the performance of a CF NBS programme. The processing of a positive screening result includes the initial information given to the parents, the invitation to the sweat test, what to do if a sweat test fails, information about the results of the sweat test, the inconclusive diagnosis and the carrier status, which is handled differently from country to country. The time until the definitive diagnosis and adequate information is given, is considered by the parents and the CF team as the most important factor. The communication of a positive NBS result is crucial. It is not a singular event but rather a process that includes ensuring the appropriate clinicians are aware of the result and that families are informed in the most efficient and effective manner to facilitate consistent and timely follow-up.
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Affiliation(s)
- Jürg Barben
- Division of Paediatric Pulmonology & CF Centre, Children’s Hospital of Eastern Switzerland, 9006 St. Gallen, Switzerland
| | - Jane Chudleigh
- School of Health Sciences, City, University of London, London EC1V 0HB, UK;
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He X, Xu T, Gu Z, Gao W, Xu LP, Pan T, Zhang X. Flexible and Superwettable Bands as a Platform toward Sweat Sampling and Sensing. Anal Chem 2019; 91:4296-4300. [DOI: 10.1021/acs.analchem.8b05875] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Xuecheng He
- Research Center for Bioengineering and Sensing Technology, Department of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
| | - Tailin Xu
- Research Center for Bioengineering and Sensing Technology, Department of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
| | - Zhen Gu
- Research Center for Bioengineering and Sensing Technology, Department of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
| | - Wei Gao
- Division of Engineering and Applied Science, California Institute of Technology, 1200 East California Boulevard, Pasadena, California 91125, United States
| | - Li-Ping Xu
- Research Center for Bioengineering and Sensing Technology, Department of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
| | - Tingrui Pan
- Department of Biomedical Engineering, University of California, Davis, California 95616, United States
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, Guangdong 518055, P. R. China
| | - Xueji Zhang
- Research Center for Bioengineering and Sensing Technology, Department of Chemistry and Biological Engineering, University of Science and Technology Beijing, Beijing 100083, P. R. China
- Beijing Advanced Innovation Center for Materials Genome Engineering, University of Science & Technology Beijing, 30 Xueyuan Road, Beijing 100083, P. R. China
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Rueegg CS, Kuehni CE, Gallati S, Jurca M, Jung A, Casaulta C, Barben J. Comparison of two sweat test systems for the diagnosis of cystic fibrosis in newborns. Pediatr Pulmonol 2019; 54:264-272. [PMID: 30609259 DOI: 10.1002/ppul.24227] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 11/27/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES In the national newborn screening programme for CF in Switzerland, we compared the performance of two sweat test methods, by investigating the feasibility and diagnostic performance of the Macroduct® collection method (with chloride mesurement) and Nanoduct® test (measuring conductivity) for diagnosing CF. STUDY-DESIGN We included all newborns with a positive screening result between 2011 and 2015 who were referred to a CF-centre for sweat testing. In the CF-centre, a Macroduct and Nanoduct sweat test were performed simultaneously. If sweat test results were positive or borderline, a DNA analysis was performed. Final diagnosis was based on genetic mutations. RESULTS Over 5 years, 445 children were screened positive and in 413 (114 with CF) at least one sweat test was performed (median age at first test, 22 days); both tests were performed in 371 children. A sweat test result was more often available with the Nanoduct compared to the Macroduct (79 vs 60%, P < 0.001). The Nanoduct was equally sensitive as the Macroduct in identifying newborns with CF (sensitivity 98 vs 99%) but less specific (specificity 79 vs 93%; P-value comparing ROC curves = 0.033). CONCLUSIONS This national multicentre study revealed high failure rates for Macroduct and Nanoduct in newborns in real life practice. While this needs to be addressed, our results suggested that performing the Nanoduct in addition to the Macroduct might speed up the diagnostic process because it more often yields valid results with comparable diagnostic performance. The addition of the Nanoduct sweat test can therefore help to reduce the stressful time of uncertainty for parents and to start appropriate treatment earlier.
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Affiliation(s)
- Corina S Rueegg
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital and Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Department of Pediatrics, Respiratory Unit, University of Bern, Bern, Switzerland
| | - Sabina Gallati
- Division of Human Genetics, University Children's Hospital Bern, Bern, Switzerland
| | - Maja Jurca
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Andreas Jung
- Division of Respiratory Medicine, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Carmen Casaulta
- Department of Pediatrics, Respiratory Unit, University of Bern, Bern, Switzerland
| | - Juerg Barben
- Division of Pediatric Pulmonology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
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Dubot P, Liang J, Dubs J, Missiak Y, Sarazin C, Couderc F, Caussé E. Sweat chloride quantification using capillary electrophoresis. Pract Lab Med 2018; 13:e00114. [PMID: 30623007 PMCID: PMC6317274 DOI: 10.1016/j.plabm.2018.e00114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 11/06/2018] [Accepted: 12/06/2018] [Indexed: 11/20/2022] Open
Abstract
Background Cystic fibrosis (CF) is the less rare and severe genetic disease among the European population. Biochemical diagnosis of CF is based on the demonstration of increased chloride concentration in sweat samples, obtained during the sweat test (ST). WynSep developed a capillary electrophoresis with contactless conductivity detection (CE-C4D) able to measure sweat chloride with a low sample volume. We evaluated the clinical feasibility of this device in a cohort of patients suspected of CF, in comparison with the common coulometric method (ChloroChek chloridometer). Methods We determined sweat chloride concentration of 65 samples from patients referred to our institution to undergo a sweat test. Each sample was submitted to coulometric method first, then WynSep-CE, with or without internal standard (IS) subject to sufficient volume sample. Results A total of 53 samples were analysed by both coulometric and WynSep-CE (using IS) methods. The method validation showed comparable analytical performances for both methods; no false positive or false negative was recorded. The two methods showed a high correlation (r = 0.993, p < 0.001) and a close agreement was demonstrated by two different statistical tests (Bland-Altman and Passing-Bablok). Conclusions WynSep-CE is an accurate, fast, easy-to-use and an appropriate method for CF diagnosis.
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Affiliation(s)
- Patricia Dubot
- Laboratoire de Biochimie, Institut Fédératif de Biologie, Hôpital Purpan, 330, av de Grande Bretagne TSA 40031, 31059 Toulouse Cedex 9, France
| | - Jing Liang
- WynSep SAS, Prologue 1, 815 La Pyrénéenne, 31670 Labège, France
| | - Jacobé Dubs
- WynSep SAS, Prologue 1, 815 La Pyrénéenne, 31670 Labège, France
| | - Yohann Missiak
- Laboratoire de Biochimie, Institut Fédératif de Biologie, Hôpital Purpan, 330, av de Grande Bretagne TSA 40031, 31059 Toulouse Cedex 9, France
| | - Cédric Sarazin
- WynSep SAS, Prologue 1, 815 La Pyrénéenne, 31670 Labège, France
| | - François Couderc
- Laboratoire de Chimie Analytique et Spectrométrie de Masse, IMRCP, UMR, 5623 Toulouse, France
| | - Elizabeth Caussé
- Laboratoire de Biochimie, Institut Fédératif de Biologie, Hôpital Purpan, 330, av de Grande Bretagne TSA 40031, 31059 Toulouse Cedex 9, France
- Corresponding author.
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Feasibility and normal values of an integrated conductivity (Nanoduct™) sweat test system in healthy newborns. J Cyst Fibros 2017; 16:465-470. [DOI: 10.1016/j.jcf.2017.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 03/12/2017] [Accepted: 04/03/2017] [Indexed: 12/30/2022]
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Farrell PM, White TB, Ren CL, Hempstead SE, Accurso F, Derichs N, Howenstine M, McColley SA, Rock M, Rosenfeld M, Sermet-Gaudelus I, Southern KW, Marshall BC, Sosnay PR. Diagnosis of Cystic Fibrosis: Consensus Guidelines from the Cystic Fibrosis Foundation. J Pediatr 2017; 181S:S4-S15.e1. [PMID: 28129811 DOI: 10.1016/j.jpeds.2016.09.064] [Citation(s) in RCA: 469] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Cystic fibrosis (CF), caused by mutations in the CF transmembrane conductance regulator (CFTR) gene, continues to present diagnostic challenges. Newborn screening and an evolving understanding of CF genetics have prompted a reconsideration of the diagnosis criteria. STUDY DESIGN To improve diagnosis and achieve standardized definitions worldwide, the CF Foundation convened a committee of 32 experts in CF diagnosis from 9 countries to develop clear and actionable consensus guidelines on the diagnosis of CF and to clarify diagnostic criteria and terminology for other disorders associated with CFTR mutations. An a priori threshold of ≥80% affirmative votes was required for acceptance of each recommendation statement. RESULTS After reviewing relevant literature, the committee convened to review evidence and cases. Following the conference, consensus statements were developed by an executive subcommittee. The entire consensus committee voted and approved 27 of 28 statements, 7 of which needed revisions and a second round of voting. CONCLUSIONS It is recommended that diagnoses associated with CFTR mutations in all individuals, from newborn to adult, be established by evaluation of CFTR function with a sweat chloride test. The latest mutation classifications annotated in the Clinical and Functional Translation of CFTR project (http://www.cftr2.org/index.php) should be used to aid in diagnosis. Newborns with a high immunoreactive trypsinogen level and inconclusive CFTR functional and genetic testing may be designated CFTR-related metabolic syndrome or CF screen positive, inconclusive diagnosis; these terms are now merged and equivalent, and CFTR-related metabolic syndrome/CF screen positive, inconclusive diagnosis may be used. International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes for use in diagnoses associated with CFTR mutations are included.
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Affiliation(s)
- Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Clement L Ren
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | | | - Frank Accurso
- Section of Pediatric Pulmonology, Colorado School of Public Health, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Nico Derichs
- CFTR Biomarker Center and Translational CF Research Group, CF Center, Pediatric Pulmonology and Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michelle Howenstine
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, and Division of Pulmonary Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Michael Rock
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Margaret Rosenfeld
- Seattle Children's Research Institute and Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Isabelle Sermet-Gaudelus
- Centres de Ressources et de Compétences pour la Mucoviscidose, Institut Necker Enfants Malades/INSERM U1151, Hôpital Necker Enfants Malades, Paris, France
| | - Kevin W Southern
- Department of Women's and Children's Health, University of Liverpool, Institute in the Park, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | | | - Patrick R Sosnay
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
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11
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Faria AG, Marson FAL, Gomez CCDS, Ribeiro MÂGDO, Morais LB, Servidoni MDF, Bertuzzo CS, Sakano E, Goto M, Paschoal IA, Pereira MC, Hessel G, Levy CE, Toro AADC, Peixoto AO, Simões MCR, Lomazi EA, Nogueira RJN, Ribeiro AF, Ribeiro JD. Quality of sweat test (ST) based on the proportion of sweat sodium (Na) and sweat chloride (Cl) as diagnostic parameter of cystic fibrosis: are we on the right way? Diagn Pathol 2016; 11:103. [PMID: 27784314 PMCID: PMC5080702 DOI: 10.1186/s13000-016-0555-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 10/20/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To assess the quality of sweat test (ST) based on the proportion of sweat sodium and sweat chloride as diagnostic parameter of cystic fibrosis (CF). METHODS A retrospective study of 5,721 sweat samples and subsequent descriptive analysis were carried out. The test was considered "of good quality" (correct) when: (i) sweat chloride was lower than 60 mEq/L, and sweat sodium was higher than sweat chloride; (ii) sweat chloride was higher than 60 mEq/L, and sweat sodium was lower than sweat chloride. RESULTS The study included 5,692/5,721 sweat samples of ST which had been requested due to clinical presentations compatible with CF and/or neonatal screenings with altered immunoreactive trypsinogen values. Considering the proportion of sweat sodium and sweat chloride as ST quality parameter, the test was performed correctly in 5,023/5,692 (88.2 %) sweat samples. The sweat chloride test results were grouped into four reference ranges for chloride (i) chloride < 30 mEq/L: 3,651/5,692 (64.1 %); (ii) chloride ≥ 30 mEq/L to < 40 mEq/L: 652/5,692 (11.5 %); (iii) ≥ 40 mEq/L to < 60 mEq/L: 673/5,692 (11.8 %); (iv) ≥ 60 mEq/L: 716/5,692 (12.6 %). In the comparative analysis, there was no association between ST quality and: (i) symptoms to indicate a ST [respiratory (p = 0.084), digestive (p = 0.753), nutritional (p = 0.824), and others (p = 0.136)], (ii) sweat weight (p = 0.416). However, there was a positive association with: (i) gender, (ii) results of ST (p < 0.001), (iii) chloride/sodium ratio (p < 0.001), (iv) subject's age at the time of ST [grouped according to category (p < 0.001) and numerical order (p < 0.001)]. For the subset of 169 patients with CF and two CFTR mutations Class I, II and/or III, in comparative analysis, there was a positive association with: (i) sweat chloride/sodium ratio (p < 0.001), (ii) sweat chloride values (p = 0.047), (iii) subject's age at the time of the ST grouped by numerical order (p = 0.001). CONCLUSIONS Considering that the quality of ST can be assessed by levels of sweat sodium and sweat chloride, an increasing number of low-quality tests could be observed in our sweat samples. The quality of the test was associated with important factors, such as gender, CF diagnosis, and subjects' age.
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Affiliation(s)
- Alethéa Guimarães Faria
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Fernando Augusto Lima Marson
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Department of Medical Genetics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Tessália Vieira de Camargo, 126, Barão Geraldo, Cidade Universitária Zeferino Vaz, CEP: 13083-887 Campinas, São Paulo Brazil
| | | | - Maria Ângela Gonçalves de Oliveira Ribeiro
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Lucas Brioschi Morais
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maria de Fátima Servidoni
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Carmen Sílvia Bertuzzo
- Department of Medical Genetics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Eulália Sakano
- Department of Otorhinolaryngology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maura Goto
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Ilma Aparecida Paschoal
- Department of Clinical Medicine, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Mônica Corso Pereira
- Department of Clinical Medicine, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gabriel Hessel
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Carlos Emílio Levy
- Department of Clinical Pathology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | | | | | | | | | | | - José Dirceu Ribeiro
- Department of Pediatrics, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
- Laboratory of Pulmonary Physiology, Center for Pediatrics Investigation, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
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12
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Barben J, Rueegg CS, Jurca M, Spalinger J, Kuehni CE. Measurement of fecal elastase improves performance of newborn screening for cystic fibrosis. J Cyst Fibros 2016; 15:313-7. [DOI: 10.1016/j.jcf.2015.12.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/17/2015] [Accepted: 12/29/2015] [Indexed: 12/31/2022]
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Abstract
Cystic Fibrosis (CF) is a rare, multisystem disease leading to significant morbidity and mortality. CF is caused by defects in the cystic fibrosis transmembrane conductance regulator protein (CFTR), a chloride and bicarbonate transporter. Early diagnosis and access to therapies provides benefits in nutrition, pulmonary health, and cognitive ability. Several screening and diagnostic tests are available to support a diagnosis. We discuss the characteristics of screening and diagnostic tests for CF and guideline-based algorithms using these tools to establish a diagnosis. We discuss classification and management of common "diagnostic dilemmas," including the CFTR-related metabolic syndrome and other CFTR-associated diseases.
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Affiliation(s)
- John Brewington
- Division of Pulmonary Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, MLC 2021, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - J P Clancy
- Division of Pulmonary Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, MLC 2021, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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Sweat conductivity and coulometric quantitative test in neonatal cystic fibrosis screening. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2015. [DOI: 10.1016/j.jpedp.2015.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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15
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Domingos MT, Magdalena NIR, Cat MNL, Watanabe AM, Rosário Filho NA. Sweat conductivity and coulometric quantitative test in neonatal cystic fibrosis screening. J Pediatr (Rio J) 2015; 91:590-5. [PMID: 26092226 DOI: 10.1016/j.jped.2015.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 02/03/2015] [Accepted: 03/11/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To compare the results obtained with the sweat test using the conductivity method and coulometric measurement of sweat chloride in newborns (NBs) with suspected cystic fibrosis (CF) in the neonatal screening program. METHODS The sweat test was performed simultaneously by both methods in children with and without CF. The cutoff values to confirm CF were >50 mmol/L in the conductivity and >60 mmol/L in the coulometric test. RESULTS There were 444 infants without CF (185 males, 234 females, and 24 unreported) submitted to the sweat test through conductivity and coulometric measurement simultaneously, obtaining median results of 32 mmol/L and 12 mmol/L, respectively. For 90 infants with CF, the median values of conductivity and coulometric measurement were 108 mmol/L and 97 mmol/L, respectively. The false positive rate for conductivity was 16.7%, and was higher than 50 mmol/L in all patients with CF, which gives this method a sensitivity of 100% (95% CI: 93.8-97.8), specificity of 96.2% (95% CI: 93.8-97.8), positive predictive value of 83.3% (95% CI: 74.4-91.1), negative predictive value of 100% (95% CI: 90.5-109.4), and 9.8% accuracy. The correlation between the methods was r=0.97 (p>0.001). The best suggested cutoff value was 69.0 mmol/L, with a kappa coefficient=0.89. CONCLUSION The conductivity test showed excellent correlation with the quantitative coulometric test, high sensitivity and specificity, and can be used in the diagnosis of CF in children detected through newborn screening.
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Affiliation(s)
- Mouseline Torquato Domingos
- Serviço de Referência em Triagem Neonatal (SRTN), Fundação Ecumênica de Proteção ao Excepcional (FEPE), Curitiba, PR, Brazil.
| | | | - Mônica Nunes Lima Cat
- Department of Pediatrics, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil
| | - Alexandra Mitiru Watanabe
- Serviço de Referência em Triagem Neonatal (SRTN), Fundação Ecumênica de Proteção ao Excepcional (FEPE), Curitiba, PR, Brazil
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16
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Vernooij-van Langen A, Dompeling E, Yntema JB, Arets B, Tiddens H, Loeber G, Dankert-Roelse J. Clinical evaluation of the Nanoduct sweat test system in the diagnosis of cystic fibrosis after newborn screening. Eur J Pediatr 2015; 174:1025-34. [PMID: 25678232 DOI: 10.1007/s00431-015-2501-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/23/2015] [Accepted: 01/28/2015] [Indexed: 01/21/2023]
Abstract
UNLABELLED After a positive newborn screening test for cystic fibrosis (CF), a sweat test is performed to confirm the diagnosis. The success rate of the generally acknowledged methods (Macroduct/Gibson and Cooke) in newborns varies between 73 and 99%. The Nanoduct sweat test system is easier to perform and less sweat is needed. The main aim of this study was to measure the success rate of the Nanoduct compared to current approved sweat test methods in a newborn population. After informed consent of the parents, newborns with a positive screening test for CF were included. The Macroduct or Gibson and Cooke and Nanoduct were performed in all infants, during the same appointment. The chloride concentration was determined by standard coulorimetry; conductivity was measured directly and converted to a NaCl molarity. One hundred eight newborns were included: 17 with CF, 7 with cystic fibrosis transmembrane regulator (CFTR)-related metabolic syndrome (CRMS), and 84 healthy children. The success rate of the Nanoduct was 93% and for the Macroduct/Gibson and Cooke 79% (McNemar, p = 0.002). The Nanoduct detected the same CF patients as the Macroduct/Gibson and Cooke; one CF patient had an equivocal result for both tests, and no patients were missed. The area under the receiver operating characteristic curve for detection of CF with the Nanoduct was 0.999, with ideal cutoff levels of 91 and 66 mmol/l, comparable to former studies. CONCLUSION The success rate of the Nanoduct to collect sufficient sweat in infants was higher compared to the Macroduct and Gibson and Cooke.
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17
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Kay DM, Langfelder-Schwind E, DeCelie-Germana J, Sharp JK, Maloney B, Tavakoli NP, Saavedra-Matiz CA, Krein LM, Caggana M, Kier C. Utility of a very high IRT/No mutation referral category in cystic fibrosis newborn screening. Pediatr Pulmonol 2015; 50:771-80. [PMID: 26098992 DOI: 10.1002/ppul.23222] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 04/17/2015] [Accepted: 05/08/2015] [Indexed: 11/11/2022]
Abstract
Newborn screening for Cystic Fibrosis (CF) began in New York in October, 2002 using immunoreactive trypsinogen (IRT)/DNA methodology. Infants with at least one CFTR mutation or very high IRT and no mutations (VHIRT) are referred for sweat testing. In a preliminary analysis, we noted a very low positive predictive value (PPV) and preponderance of Hispanic infants in the group of infants with CF referred for VHIRT, which led to a decision to revise, but not eliminate, the VHIRT category. Automatic referral for specimens with VHIRT collected on the day of birth was eliminated, and the VHIRT threshold was raised from 0.2% to 0.1%. In this report, we describe outcomes from VHIRT referrals among 2.4 million infants screened between March 2003 and February 2013. Following the algorithm change, referrals decreased by 37.8% overall (annual mean 1,485 vs. 923), and the VHIRT PPV improved (0.6-1.0%). The number of infants diagnosed has remained consistent at 1 in 4,400 births. The proportion of Black/Hispanic/Asian/Other infants with confirmed CF, CFTR-related metabolic syndrome (CRMS), or possible CF/CRMS was 21.3% in infants with 1-2 mutations, but 75.8% in the VHIRT group. In conclusion, although the PPV among VHIRT referrals remains low, had this category never been implemented, 24 infants with confirmed CF, and 9 infants with CRMS or possible CF/CRMS, most of whom were Hispanic, would have been missed over the 10 years. Information from this study may be helpful in assessing the need for the VHIRT category and algorithm changes in other screening programs.
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Affiliation(s)
- Denise M Kay
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, New York
| | | | | | - Jack K Sharp
- Departments of Pediatrics, Duke University, Durham, NC and State University of New York (SUNY) at Buffalo, Buffalo, New York
| | - Breanne Maloney
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, New York
| | - Norma P Tavakoli
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, New York.,Department of Biomedical Sciences, University at Albany, Albany, New York
| | - Carlos A Saavedra-Matiz
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, New York
| | - Lea M Krein
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, New York
| | - Michele Caggana
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, New York
| | - Catherine Kier
- University Medical Center at Stony Brook, Stony Brook, New York
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DeMarco ML, Dietzen DJ, Brown SM. Sweating the small stuff: adequacy and accuracy in sweat chloride determination. Clin Biochem 2014; 48:443-7. [PMID: 25530017 DOI: 10.1016/j.clinbiochem.2014.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 12/09/2014] [Accepted: 12/10/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Sweat chloride testing is the gold standard for diagnosis of cystic fibrosis (CF). Our objectives were to: 1) describe variables that determine sweat rate; 2) determine the analytic and diagnostic capacity of sweat chloride analysis across the range of observed sweat rates; and 3) determine the biologic variability of sweat chloride concentration. METHODS A retrospective analysis was performed using data from all sweat chloride tests performed at St. Louis Children's Hospital over a 21-month period. RESULTS A total of 1397 sweat chloride tests (1155 sufficient [≥75 mg], 242 insufficient [<75 mg]), were performed on 904 individuals. The sweat weight collected from forearms was statistically greater than that collected from legs. There was a negligible correlation between sweat weight and chloride concentration (r=-0.06). The mean individual biologic CV calculated from individuals with two or more sweat collections ≥75 mg was 13.1% (95% CI: 11.3-14.9%; range 0-88%) yielding a reference change value of 36%. Using 60 mmol/L as the diagnostic chloride cutoff, 100% of CF cases were detected whether a minimum sweat weight of 75, 40, or 20 mg was required. CONCLUSIONS 1) Collection of sweat from forearms is preferable to upper legs, particularly in very young infants; 2) sweat chloride concentrations are not highly dependent upon sweat rate; 3) a change in sweat chloride concentration exceeding 36% may be considered a clinically significant response to cystic fibrosis transmembrane receptor targeted therapy, and 4) sweat collections of less than 75 mg provide clinically accurate information.
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Affiliation(s)
- Mari L DeMarco
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
| | - Dennis J Dietzen
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Sarah M Brown
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, MO, USA; Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
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Abdulhamid I, Kleyn M, Langbo C, Gregoire-Bottex M, Schuen J, Shanmugasundaram K, Nasr SZ. Improving the Rate of Sufficient Sweat Collected in Infants Referred for Sweat Testing in Michigan. Glob Pediatr Health 2014; 1:2333794X14553625. [PMID: 27335913 PMCID: PMC4804676 DOI: 10.1177/2333794x14553625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective. Sweat collected for testing should have quantity not sufficient (QNS) rate of ≤10% in babies ≤3 months of age. Michigan (MI) cystic fibrosis (CF) centers' QNS rates were 12% to 25% in 2009. This project was initiated to reduce sweat QNS rates in MI. Methods/Steps. (a) Each center's sweat testing procedures were reviewed by a consultant. (b) Each center received a report with recommendations to improve QNS rates. (c) Technicians visited other participating centers to observe their procedures. Results. A total of 778 infants were identified as positive via CF newborn screening over a 2-year period. The mean age at time of sweat test was 23.2 days (SD ± 13.0 days). The overall QNS percent decreased from 14.4% to 9.5% (P = .04) during the study. Conclusion. This project and teamwork approach led to a decrease of sweat test QNS rates, opportunities to solve a common problem, and improved quality of care.
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Affiliation(s)
- Ibrahim Abdulhamid
- Children's Hospital of Michigan Cystic Fibrosis Center, Detroit, MI, USA
| | - Mary Kleyn
- Michigan Department of Community Health, Lansing, MI, USA
| | - Carrie Langbo
- Michigan Department of Community Health, Lansing, MI, USA
| | | | - John Schuen
- Helen DeVos Children's Hospital Cystic Fibrosis Center, Grand Rapids, MI, USA
| | | | - Samya Z Nasr
- University of Michigan Cystic Fibrosis Center, Ann Arbor, MI, USA
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20
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Collins MN, Brawley CB, McCracken CE, Shankar PRV, Schechter MS, Rogers BB. Risk factors for quantity not sufficient sweat collection in infants 3 months or younger. Am J Clin Pathol 2014; 142:72-5. [PMID: 24926088 DOI: 10.1309/ajcplhg2buvbt5ly] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES The purpose is to identify demographic characteristics associated with a quantity not sufficient (QNS) sweat collection in infants 3 months or younger. METHODS History of premature birth, infant race and sex, gestational age at delivery, and weight of the infant were compared with QNS collection. RESULTS Of 221 sweat collections from 197 infants, 25 were QNS. Infant weight less than 3 kg and history of prematurity were associated with QNS collection (P < .001). Thirteen (30.2%) of 43 infants weighing less than 3 kg had QNS collections compared with 12 (7.9%) of 151 infants 3 kg or more. Twelve (46.2%) premature infants had QNS collections compared with 13 (7.6%) term infants. Lower birth gestational age and corrected gestational age were associated with QNS collections. Six (86%) of seven infants who weighed less than 3 kg, had a history of prematurity, and were more than 54 days old at testing had a QNS result. Sex and race did not correlate with QNS collections. CONCLUSIONS Weight less than 3 kg and history of prematurity are associated with an increased chance of QNS sweat collections.
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Affiliation(s)
- Matthew N. Collins
- Departments of Pathology, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Cindy B. Brawley
- Departments of Pathology, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Courtney E. McCracken
- Pediatrics, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Prabhu R. V. Shankar
- Pediatrics, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
| | - Michael S. Schechter
- Pediatrics, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
- Virginia Commonwealth University, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - Beverly Barton Rogers
- Departments of Pathology, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
- Pediatrics, Children’s Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA
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Traeger N, Shi Q, Dozor AJ. Relationship between sweat chloride, sodium, and age in clinically obtained samples. J Cyst Fibros 2013; 13:10-4. [PMID: 23916616 DOI: 10.1016/j.jcf.2013.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 06/18/2013] [Accepted: 07/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The relationship between sweat electrolytes and age is uncertain, as is the value of measuring sodium or the chloride:sodium ratio. METHODS 13,785 sweat tests performed over 23 years at one center through the Macroduct collection in clinically obtained samples were analyzed. RESULTS Sweat chloride tended to decrease over the first year of life, slowly increase until the fourth decade, then either level off or slightly decrease. In children, sweat sodium overlapped between those with positive and negative sweat tests, but not in adults. If the sweat test was positive, there was a higher likelihood of having a chloride:sodium ratio >1, but most subjects with a ratio >1 did not have CF. CONCLUSIONS Sweat chloride and sodium vary with age. Measurement of sweat sodium did not add discriminatory value. The proportion of subjects with a chloride:sodium ratio >1, with or without CF, varied greatly between age ranges.
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Affiliation(s)
- Nadav Traeger
- New York Medical College, Department of Pediatrics, Division of Pediatric Pulmonology, Allergy, and Sleep Medicine Munger Pavilion Room 106, Valhalla, NY 10595, United States; The Armond V. Mascia, MD Cystic Fibrosis Center of the Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY, United States.
| | - Qiuhu Shi
- New York Medical College, Department of Epidemiology and Community Health, School of Health Sciences and Practice, Valhalla, NY 10595, United States
| | - Allen J Dozor
- New York Medical College, Department of Pediatrics, Division of Pediatric Pulmonology, Allergy, and Sleep Medicine Munger Pavilion Room 106, Valhalla, NY 10595, United States; The Armond V. Mascia, MD Cystic Fibrosis Center of the Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY, United States
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Effects of immediate telephone follow-up with providers on sweat chloride test timing after cystic fibrosis newborn screening identifies a single mutation. J Pediatr 2013; 162:522-9. [PMID: 23102590 PMCID: PMC3582754 DOI: 10.1016/j.jpeds.2012.08.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 08/15/2012] [Accepted: 08/29/2012] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess whether reporting "possible cystic fibrosis (CF)" newborn screening (NBS) results via fax plus simultaneous telephone contact with primary care providers (PCPs) versus fax alone influenced 3 outcomes: undergoing a sweat chloride test, age at sweat chloride testing, and undergoing sweat testing before age 8 weeks. STUDY DESIGN This was a retrospective cohort comparison of infants born in Wisconsin whose PCP received a telephone intervention (n = 301) versus recent historical controls whose PCP did not (n = 355). Intervention data were collected during a longitudinal research and quality improvement effort; deidentified comparison data were constructed from auxiliary NBS tracking information. Parametric and nonparametric statistical analyses were performed for group differences. RESULTS Most infants (92%) with "possible CF" NBS results whose PCP lacked telephone intervention ultimately underwent sweat testing, underlining efficacy for fax-only reporting. Telephone intervention was significantly associated with improvements in the infants undergoing sweat testing at age ≤6 weeks and <8 weeks and a slight, statistically nonsignificant 3.5-day reduction in the infants' age at sweat testing. The effect of telephone intervention was greater for PCPs whose patients underwent sweat testing at community-affiliated medical centers versus those whose patients did so at academic medical centers (P = .008). CONCLUSION Reporting "possible CF" NBS results via fax plus simultaneous telephone follow-up with PCPs increases the rate of sweat chloride testing before 8 weeks of age, when affected infants are more likely to receive full benefits of early diagnosis and treatment.
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Laguna TA, Lin N, Wang Q, Holme B, McNamara J, Regelmann WE. Comparison of quantitative sweat chloride methods after positive newborn screen for cystic fibrosis. Pediatr Pulmonol 2012; 47:736-42. [PMID: 22786625 PMCID: PMC3856863 DOI: 10.1002/ppul.21608] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 11/03/2011] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Rapid and reliable confirmatory sweat testing following a positive newborn screen (NBS) for cystic fibrosis (CF) is preferred to allow for early diagnosis and to decrease parental anxiety. The Cystic Fibrosis Foundation (CFF) recently recommended a quantity not sufficient (QNS) rate of ≤ 10% in infants <3 months of age referred for quantitative sweat chloride analysis. Two CFF-approved methods are available by which to quantitatively measure chloride concentration in sweat. Our objective was to compare the performance of the Macroduct® sweat collection system (MSCS) with the Gibson and Cooke technique (GCT) in the acquisition of samples for the determination of sweat chloride concentration in infants with a positive Minnesota State NBS for CF. METHODS A retrospective database review of infants referred to the core Minnesota CF Center or its affiliate site for confirmatory sweat testing was performed to compare the QNS rates for the two techniques. Associations between birthweight, age at test, race, and QNS rates were examined. RESULTS Five hundred sixty-eight infants were referred for 616 sweat tests from March 2006 to January 2010. The mean age was 32.8 days at the initial sweat test. The GCT had a significantly higher QNS rate compared to the MSCS (15.4% vs. 2.1%, P < 0.0001). There was no association between age and the probability of QNS. The probability of QNS decreased as birthweight increased (P = 0.02). After adjusting for age, the odds of QNS using the GCT remained 8.34 (95% CI: 3.72-18.71) times that of the MSCS. Non-White infants had a significantly higher likelihood of QNS compared to non-Hispanic White infants (P = 0.0025). CONCLUSIONS Given the performance of the MSCS, the Minnesota CF Center has implemented the MSCS as its method of choice for diagnostic sweat testing in infants following a positive state NBS.
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Affiliation(s)
- Theresa A Laguna
- Department of Pediatrics, University of Minnesota School of Medicine and The Amplatz Children's Hospital, Minneapolis, Minnesota, USA.
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A review of pathophysiology and management of fetuses and neonates with meconium ileus for the pediatric surgeon. J Pediatr Surg 2012; 47:772-81. [PMID: 22498395 DOI: 10.1016/j.jpedsurg.2012.02.019] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Meconium ileus (MI) is the earliest clinical manifestation of cystic fibrosis (CF), occurring in up to 20% of patients with CF. Our aim was to review and integrate current knowledge about the diagnosis and management of fetuses and neonates with MI that may aid the pediatric surgeon in caring for these patients. METHODS We identified areas of interest including pathophysiology, prenatal diagnosis, nonoperative and operative management, postoperative management, and prognosis. We performed a Medline search using the search term meconium ileus for English language articles published in the last 20 years. We reviewed reference lists to identify other articles of historical significance. RESULTS Meconium ileus is primarily associated with CF transmembrane (conductance) regulator mutations F508del, G542X, W1282X, R553X, and G551D, and modifier genes have been found to explain approximately 17% of the phenotypic variability. Mouse, pig, and ferret models for CF demonstrate neonatal bowel obstruction mimicking MI. Sonographic findings of hyperechoic masses and dilated bowel in a high-risk fetus are suggestive of MI. Less than 7% of low-risk fetuses with hyperechoic bowel will have MI. Contemporary series of noninvasive management with Gastrografin enema report success rates of 36% to 39%, significantly lower than historical values. The optimal surgical technique remains controversial, although primary anastomosis results in surgical complication rates between 21% and 31%, higher than those noted with delayed anastomosis. Pulmonary function for patients with CF and MI at 15 and 25 years old is similar to those without MI, although height and weight percentiles may be lower. CONCLUSIONS This review for pediatric surgeons presents an examination of the literature and synthesizes current information about the pathophysiology, prenatal diagnosis, nonoperative and operative management, postoperative management, and prognosis of the patient with CF and MI.
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Abstract
There are few reports of cystic fibrosis (CF) diagnosed in premature infants. We describe the clinical course of three patients, from our neonatal intensive care units, who were diagnosed with CF, and discuss the existing literature and treatment considerations.
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Affiliation(s)
- KD Lu
- Division of Pulmonary, Department of Pediatrics, John Hopkins University, Baltimore, MD, USA
| | - C Engmann
- Division of Neonatology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - F Moya
- Division of Neonatology, Neonatal Intensive Care Unit at NHRMC, New Hanover Regional Medical Center, Wilmington, NC, USA
| | - M Muhlebach
- Division of Pulmonology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
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Sosnay PR, Castellani C, Corey M, Dorfman R, Zielenski J, Karchin R, Penland CM, Cutting GR. Evaluation of the disease liability of CFTR variants. Methods Mol Biol 2011; 742:355-372. [PMID: 21547743 DOI: 10.1007/978-1-61779-120-8_21] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Over 1600 novel sequence variants in the CFTR gene have been reported to the CF Mutation Database (http://www.genet.sickkids.on.ca/cftr/Home.html). While about 25 mutations are well characterized by clinical studies and functional assays, the disease liability of most of the remaining mutations is either unclear or unknown. This gap in knowledge has implications for diagnosis, therapy selection, and counseling for patients and families carrying an uncharacterized CFTR mutation. This chapter will describe a critical approach to assessing the disease implications of CFTR mutations utilizing clinical data, literature review, functional testing, and bioinformatic in silico methods.
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Affiliation(s)
- Patrick R Sosnay
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Kleyn M, Korzeniewski S, Grigorescu V, Young W, Homnick D, Goldstein-Filbrun A, Schuen J, Nasr S. Predictors of insufficient sweat production during confirmatory testing for cystic fibrosis. Pediatr Pulmonol 2011; 46:23-30. [PMID: 20812243 DOI: 10.1002/ppul.21318] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 04/26/2010] [Accepted: 04/29/2010] [Indexed: 01/21/2023]
Abstract
Michigan's Newborn Screening (NBS) Program began statewide screening for cystic fibrosis (CF) in October 2007. Confirmatory sweat testing is performed in infants having initial immunoreactive trypsinogen concentrations ≥ 99.8th percentile or ≥ 96 th percentile and at least one CF mutation identified by DNA analysis. Some infants fail to produce a sufficient quantity of sweat (QNS-quantity not sufficient) to test for CF, meaning disease confirmation is delayed and sweat testing is later repeated. In this study, we evaluate predictors of QNS results. Information from the linked birth certificates and NBS diagnostic confirmation data were used. The study population was resident infants born in Michigan in 2008 who underwent a sweat test. Bivariate analyses revealed that preterm birth, low birth weight, CF care center, and race were significantly associated with QNS sweat testing results. Adjusted analyses indicated that preterm infants were 2.4 times more likely to have QNS results (95% CI 0.9, 6.4). When age at time of test, accounting for gestational age (gestational age at delivery plus postdelivery age of life=corrected age), was used in the multivariable model, infants <39 weeks were 7.4 times more likely to have QNS results (95% CI 2.5, 21.8). Waiting to sweat test until an infant is aged 39 weeks or more (corrected age) would likely reduce the rate of QNS results, thereby reducing the burden of repeat sweat testing on families and healthcare providers. Further research is necessary to understand the impact of potential delays in diagnosis/treatment relative to postponing sweat testing.
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Affiliation(s)
- Mary Kleyn
- Michigan Department of Community Health, Lansing, Michigan, USA.
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Legrys VA, McColley SA, Li Z, Farrell PM. The need for quality improvement in sweat testing infants after newborn screening for cystic fibrosis. J Pediatr 2010; 157:1035-7. [PMID: 20843526 PMCID: PMC6326081 DOI: 10.1016/j.jpeds.2010.07.053] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 06/02/2010] [Accepted: 07/28/2010] [Indexed: 11/19/2022]
Abstract
The proportion of insufficient sweat tests after positive newborn screening for cystic fibrosis was determined. Infants ≤ 3 months old had a mean (± standard deviation) rate of 7.2% (± 7.6) (range, 0% to 40%). Collection methods did not affect the rates. The high and variable rates indicate a need for quality improvement.
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Affiliation(s)
- Vicky A Legrys
- School of Medicine, Division of Clinical Laboratory Science, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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29
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Sermet-Gaudelus I, Munck A, Rota M, Roussey M, Feldmann D. Recommandations françaises pour la réalisation et l’interprétation du test de la sueur dans le cadre du dépistage néonatal de la mucoviscidose. Arch Pediatr 2010; 17:1349-58. [DOI: 10.1016/j.arcped.2010.06.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 06/24/2010] [Indexed: 11/26/2022]
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30
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Taylor CJ, Hardcastle J, Southern KW. Physiological measurements confirming the diagnosis of cystic fibrosis: the sweat test and measurements of transepithelial potential difference. Paediatr Respir Rev 2009; 10:220-6. [PMID: 19879513 DOI: 10.1016/j.prrv.2009.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Revised: 05/19/2009] [Accepted: 05/26/2009] [Indexed: 11/15/2022]
Abstract
Post-natal screening allied with genetic mutation testing has altered our perception of cystic fibrosis (CF) as a clinical entity. Increasingly, infants identified through screening programmes have few or no symptoms or present with atypical forms of the disease. We review how the sweat test has evolved to be the gold standard for confirming the diagnosis of CF and examine its limitations. Other physiological measurements, including nasal potential difference and intestinal current measurement, which might aid in establishing the diagnosis, particularly in patients exhibiting a mild phenotype, are also considered.
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Affiliation(s)
- C J Taylor
- Sheffield Paediatric Cystic Fibrosis Centre, Sheffield, Academic Unit of Child Health, University of Sheffield, UK.
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31
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Coakley J, Scott S, Mackay R, Greaves R, Jolly L, Massie J, Mishra A, Bransden A, Doery JCG, Chiriano A, Robins H. Sweat testing for cystic fibrosis: standards of performance in Australasia. Ann Clin Biochem 2009; 46:332-7. [DOI: 10.1258/acb.2009.009023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Accurate measurement of sweat chloride concentration is essential for the diagnosis of cystic fibrosis (CF). We surveyed all laboratories enrolled in the Royal College of Pathologists of Australasia Quality Assurance Program (QAP) for Sweat Electrolytes to determine how closely they comply with the Australian Guidelines for the performance of the sweat test for the diagnosis of CF. Methods A detailed questionnaire covering most aspects of sweat collection and analysis was sent to all participating laboratories in 2007. Results Twenty out of 38 laboratories completed the questionnaire. While adherence to accepted guidelines was noted in many areas, the following main variations were recorded: some laboratories were not doing enough sweat tests to maintain expertise; some were not collecting sweat for the recommended collection time; sweat conductivity was the only test available in some laboratories; there was a lack of agreement between the sweat chloride concentration used to indicate CF or define an equivocal result. Conclusions There is room for improvement in the performance of the sweat test in some laboratories in Australasia. The Sweat Testing Working Party of the Australasian Association of Clinical Biochemists is the appropriate body to address the problems involved in sweat testing and to bring about change.
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Affiliation(s)
- John Coakley
- Department of Biochemistry, The Children's Hospital at Westmead, Westmead
| | - Sue Scott
- RCPA Chemical Pathology Quality Assurance Programs, Adelaide, Australia
| | - Richard Mackay
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Ronda Greaves
- Department of Clinical Biochemistry, The Royal Children's Hospital, Melbourne
| | - Lisa Jolly
- RCPA Chemical Pathology Quality Assurance Programs, Adelaide, Australia
| | - John Massie
- Department of Respiratory Medicine, The Royal Children's Hospital, Melbourne
| | | | - Anna Bransden
- Department of Chemical Pathology, Royal Brisbane Hospital, Brisbane
| | - James C G Doery
- Department of Biochemistry, Monash Medical Centre and Department of Medicine, Monash University, Melbourne
| | - Angela Chiriano
- Department of Clinical Biochemistry, The Royal Children's Hospital, Melbourne
| | - Heather Robins
- Department of Biochemistry, The Canberra Hospital, ACT, Australia
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32
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Jayaraj R, Barton PV, Newland P, Mountford R, Shaw NJ, Mccarthy E, Isherwood DM, Southern KW. A reference interval for sweat chloride in infants aged between five and six weeks of age. Ann Clin Biochem 2009; 46:73-8. [DOI: 10.1258/acb.2008.008081] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background This study was designed to establish a reference interval for sweat chloride for infants without evidence of cystic fibrosis (CF), aged between 5 wk and 6 wk, a time when sweat testing is an integral part of newborn screening for CF. In addition, we compared the gold standard method of sweat testing (quantitative pilocarpine iontophoresis [QPIT, coulometry]) with an emerging methodology (Macroduct™ [ISE]). Methods This was a prospective study on healthy infants at 5–6 wk of age. Sweat collection was undertaken at home on both outer thigh areas using two methods (QPIT and Macroduct™). The order of testing was randomly assigned. Filter paper samples (QPIT) were analysed using flame photometry and coulometry. Macroduct™ samples were analysed using ion-selective electrodes (ISE, Abbott Architect c8000, UK). Results Insufficient sweat was collected on 28 occasions with the QPIT (coulometry) method and on 31 with the Macroduct™ (ISE) capillary system. We achieved a 92% success rate in undertaking two sweat collections consecutively (n = 177). Sweat chloride concentrations were normally distributed with excellent limits of agreement between the two methods of sweat collection and analysis (n = 150). Median (IQR) sweat chloride was 11.2 mmol/L (8–13) with QPIT (coulometry) method with a 99.5th centile (n = 165) of 24 mmol/L. Conclusion The Macroduct™ (ISE) capillary sweat collection system is valid in this age group. Sweat chloride concentrations above 30 mmol/L should prompt assessment in a specialist CF centre.
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Affiliation(s)
| | - Paul V Barton
- Department of Clinical Biochemistry, Royal Liverpool Children's Hospital
| | - Paul Newland
- Department of Clinical Biochemistry, Royal Liverpool Children's Hospital
| | | | - Nigel J Shaw
- Department of Neonatal Medicine, Liverpool Women's Hospital, Liverpool, UK
| | | | - David M Isherwood
- Department of Clinical Biochemistry, Royal Liverpool Children's Hospital
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33
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Mayell S, Munck A, Craig J, Sermet I, Brownlee K, Schwarz M, Castellani C, Southern K. A European consensus for the evaluation and management of infants with an equivocal diagnosis following newborn screening for cystic fibrosis. J Cyst Fibros 2009; 8:71-8. [DOI: 10.1016/j.jcf.2008.09.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 09/16/2008] [Accepted: 09/17/2008] [Indexed: 11/29/2022]
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Farrell PM, Rosenstein BJ, White TB, Accurso FJ, Castellani C, Cutting GR, Durie PR, Legrys VA, Massie J, Parad RB, Rock MJ, Campbell PW. Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report. J Pediatr 2008; 153:S4-S14. [PMID: 18639722 PMCID: PMC2810958 DOI: 10.1016/j.jpeds.2008.05.005] [Citation(s) in RCA: 671] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Newborn screening (NBS) for cystic fibrosis (CF) is increasingly being implemented and is soon likely to be in use throughout the United States, because early detection permits access to specialized medical care and improves outcomes. The diagnosis of CF is not always straightforward, however. The sweat chloride test remains the gold standard for CF diagnosis but does not always give a clear answer. Genotype analysis also does not always provide clarity; more than 1500 mutations have been identified in the CF transmembrane conductance regulator (CFTR) gene, not all of which result in CF. Harmful mutations in the gene can present as a spectrum of pathology ranging from sinusitis in adulthood to severe lung, pancreatic, or liver disease in infancy. Thus, CF identified postnatally must remain a clinical diagnosis. To provide guidance for the diagnosis of both infants with positive NBS results and older patients presenting with an indistinct clinical picture, the Cystic Fibrosis Foundation convened a meeting of experts in the field of CF diagnosis. Their recommendations, presented herein, involve a combination of clinical presentation, laboratory testing, and genetics to confirm a diagnosis of CF.
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Affiliation(s)
- Philip M. Farrell
- Department of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Frank J. Accurso
- Department of Pediatrics, University of Colorado Health Sciences Center, Denver, CO
| | | | - Garry R. Cutting
- Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD
| | - Peter R. Durie
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Vicky A. Legrys
- Department of Allied Health Sciences, University of North Carolina, Chapel Hill, NC
| | - John Massie
- Department of Respiratory Medicine, Royal Children’s Hospital, Melbourne, Australia
| | - Richard B. Parad
- Department of Newborn Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Michael J. Rock
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Desax MC, Ammann RA, Hammer J, Schoeni MH, Barben J. Nanoduct sweat testing for rapid diagnosis in newborns, infants and children with cystic fibrosis. Eur J Pediatr 2008; 167:299-304. [PMID: 17436014 DOI: 10.1007/s00431-007-0485-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2007] [Revised: 03/21/2007] [Accepted: 03/21/2007] [Indexed: 10/23/2022]
Abstract
Determination of chloride concentration in sweat is the current diagnostic gold standard for Cystic Fibrosis (CF). Nanoduct is a new analyzing system measuring conductivity which requires only 3 microliters of sweat and gives results within 30 minutes. The aim of the study was to evaluate the applicability of this system in a clinical setting of three children's hospitals and borderline results were compared with sweat chloride concentration. Over 3 years, 1,041 subjects were tested and in 946 diagnostic results were obtained. In 95 children, Nanoduct failed (9.1% failure rate), mainly due to failures in preterm babies and newborns. Assuming 59 mmol/L as an upper limit of normal conductivity, all our 46 CF patients were correctly diagnosed (sensitivity 100%, 95% CI: 93.1-100; negative predicted value 100% (95% CI: 99.6-100) and only 39 non CF's were false positive (39/900, 4.3%; specificity 95.7%, 95%CI: 94.2-96.9, positive predicted value 54.1% with a 95%CI: 43.4-65.0). Increasing the diagnostic limit to 80 mmol/L, the rate fell to 0.3% (3/900). CF patients had a median conductivity of 115 mmol/L; the non-CF a median of 37 mmol/L. In conclusion, the Nanoduct test is a reliable diagnostic tool for CF diagnosis: It has a failure rate comparable to other sweat tests and can be used as a simple bedside test for fast and reliable exclusion, diagnosis or suspicion of CF. In cases with borderline conductivity (60-80 mmol/L) other additional methods (determination of chloride and genotyping) are indicated.
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36
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LeGrys VA, Yankaskas JR, Quittell LM, Marshall BC, Mogayzel PJ. Diagnostic sweat testing: the Cystic Fibrosis Foundation guidelines. J Pediatr 2007; 151:85-9. [PMID: 17586196 DOI: 10.1016/j.jpeds.2007.03.002] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Revised: 01/09/2007] [Accepted: 03/01/2007] [Indexed: 11/26/2022]
Affiliation(s)
- Vicky A LeGrys
- Division of Clinical Laboratory Science, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7145, USA.
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37
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Comeau AM, Accurso FJ, White TB, Campbell PW, Hoffman G, Parad RB, Wilfond BS, Rosenfeld M, Sontag MK, Massie J, Farrell PM, O'Sullivan BP. Guidelines for implementation of cystic fibrosis newborn screening programs: Cystic Fibrosis Foundation workshop report. Pediatrics 2007; 119:e495-518. [PMID: 17272609 DOI: 10.1542/peds.2006-1993] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Newborn screening for cystic fibrosis offers the opportunity for early intervention and improved outcomes. This summary, resulting from a workshop sponsored by the Cystic Fibrosis Foundation to facilitate implementation of widespread high quality cystic fibrosis newborn screening, outlines the steps necessary for success based on the experience of existing programs. Planning should begin with a workgroup composed of those who will be responsible for the success of the local program, typically including the state newborn screening program director and cystic fibrosis care center directors. The workgroup must develop a screening algorithm based on program resources and goals including mechanisms available for sample collection, regional demographics, the spectrum of cystic fibrosis disease to be detected, and acceptable failure rates of the screen. The workgroup must also ensure that all necessary guidelines and resources for screening, diagnosis, and care be in place prior to cystic fibrosis newborn screening implementation. These include educational materials for parents and primary care providers; systems for screening and for providing diagnostic testing and counseling for screen-positive infants and their families; and protocols for care of this unique population. This summary explores the benefits and risks of various screening algorithms, including complex situations that can occur involving unclear diagnostic results, and provides guidelines and sample materials for state newborn screening programs to develop and implement high quality screening for cystic fibrosis.
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Affiliation(s)
- Anne Marie Comeau
- New England Newborn Screening Program and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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