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Anton-Păduraru DT, Azoicăi AN, Trofin F, Mîndru DE, Murgu AM, Bocec AS, Iliescu Halițchi CO, Ciongradi CI, Sȃrbu I, Iliescu ML. Diagnosing Cystic Fibrosis in the 21st Century-A Complex and Challenging Task. Diagnostics (Basel) 2024; 14:763. [PMID: 38611676 PMCID: PMC11012009 DOI: 10.3390/diagnostics14070763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/24/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Cystic fibrosis (CF) is a chronic and potentially life-threatening condition, wherein timely diagnosis assumes paramount significance for the prompt initiation of therapeutic interventions, thereby ameliorating pulmonary function, addressing nutritional deficits, averting complications, mitigating morbidity, and ultimately enhancing the quality of life and extending longevity. This review aims to amalgamate existing knowledge to provide a comprehensive appraisal of contemporary diagnostic modalities pertinent to CF in the 21st century. Deliberations encompass discrete delineations of each diagnostic modality and the elucidation of potential diagnostic quandaries encountered in select instances, as well as the delineation of genotype-phenotype correlations germane to genetic counseling endeavors. The synthesis underscores that, notwithstanding the availability and strides in diagnostic methodologies, including genetic assays, the sweat test (ST) retains its position as the preeminent diagnostic standard for CF, serving as a robust surrogate for CFTR functionality. Prospective clinical investigations in the realm of CF should be orchestrated with the objective of discerning novel diagnostic modalities endowed with heightened specificity and sensitivity.
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Affiliation(s)
- Dana-Teodora Anton-Păduraru
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
| | - Alice Nicoleta Azoicăi
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
| | - Felicia Trofin
- Department of Preventive Medicine and Interdisciplinarity—Microbiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Dana Elena Mîndru
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
| | - Alina Mariela Murgu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
| | - Ana Simona Bocec
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
| | - Codruța Olimpiada Iliescu Halițchi
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania; (D.-T.A.-P.); (A.N.A.); (D.E.M.); (A.M.M.); (A.S.B.); (C.O.I.H.)
| | - Carmen Iulia Ciongradi
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
- 2nd Department of Surgery, Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Ioan Sȃrbu
- “Sf.Maria” Children Emergency Hospital, 700309 Iaṣi, Romania; (C.I.C.); (I.S.)
- 2nd Department of Surgery, Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania
| | - Maria Liliana Iliescu
- Department of Preventive Medicine and Interdisciplinarity—Public Health and Health Management, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iaṣi, Romania;
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Bucher BM, Wright BA, Weiner RL. Elevation of sweat chloride levels in a patient with CFTR-related metabolic syndrome receiving dexmethylphenidate and guanfacine. Pediatr Pulmonol 2022; 57:2264-2266. [PMID: 35570399 DOI: 10.1002/ppul.25975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/22/2022] [Accepted: 05/13/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Bridget M Bucher
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Brittany A Wright
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Rebecca L Weiner
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Raraigh KS, Paul KC, Goralski JL, Worthington EN, Faino AV, Sciortino S, Wang Y, Aksit MA, Ling H, Osorio DL, Onchiri FM, Patel SU, Merlo CA, Montemayor K, Gibson RL, West NE, Thakerar A, Bridges RJ, Sheppard DN, Sharma N, Cutting GR. CFTR bearing variant p.Phe312del exhibits function inconsistent with phenotype and negligible response to ivacaftor. JCI Insight 2022; 7:148841. [PMID: 35315358 PMCID: PMC8986068 DOI: 10.1172/jci.insight.148841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
The chloride channel dysfunction caused by deleterious cystic fibrosis transmembrane conductance regulator (CFTR) variants generally correlates with severity of cystic fibrosis (CF). However, 3 adults bearing the common severe variant p.Phe508del (legacy: F508del) and a deletion variant in an ivacaftor binding region of CFTR (p.Phe312del; legacy: F312del) manifested only elevated sweat chloride concentration (sw[Cl-]; 87-105 mEq/L). A database review of 25 individuals with F312del and a CF-causing variant revealed elevated sw[Cl-] (75-123 mEq/L) and variable CF features. F312del occurs at a higher-than-expected frequency in the general population, confirming that individuals with F312del and a CF-causing variant do not consistently develop overt CF features. In primary nasal cells, CFTR bearing F312del and F508del generated substantial chloride transport (66.0% ± 4.5% of WT-CFTR) but did not respond to ivacaftor. Single-channel analysis demonstrated that F312del did not affect current flow through CFTR, minimally altered gating, and ablated the ivacaftor response. When expressed stably in CF bronchial epithelial (CFBE41o-) cells, F312del-CFTR demonstrated residual function (50.9% ± 3.3% WT-CFTR) and a subtle decrease in forskolin response compared with WT-CFTR. F312del provides an exception to the established correlation between CFTR chloride transport and CF phenotype and informs our molecular understanding of ivacaftor response.
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Affiliation(s)
| | | | - Jennifer L Goralski
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Erin N Worthington
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anna V Faino
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Stanley Sciortino
- California Department of Public Health, Genetic Disease Screening Program, Richmond, California, USA
| | - Yiting Wang
- University of Bristol, Bristol, United Kingdom
| | | | - Hua Ling
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | - Amita Thakerar
- Rosalind Franklin University of Medicine and Science, Center for Genetic Diseases, North Chicago, Illinois, USA
| | - Robert J Bridges
- Rosalind Franklin University of Medicine and Science, Center for Genetic Diseases, North Chicago, Illinois, USA
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Cimbalo C, Tosco A, Terlizzi V, Sepe A, Castaldo A, Salvadori L, Raia V. Elevated sweat chloride test: is it always cystic fibrosis? Ital J Pediatr 2021; 47:112. [PMID: 33990208 PMCID: PMC8120719 DOI: 10.1186/s13052-021-01060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The sweat chloride test (ST) is the gold standard for cystic fibrosis (CF) diagnosis in symptomatic patients, within the newborn screening and in the follow-up of CF patients during molecular therapies. However, false positives have been reported in patients with different diseases. We describe and discuss 4 cases due to different clinical conditions in which we recorded false positive ST, and the test remained altered for a period of varying length. CASES PRESENTATION Case 1: Eight months old female child suffering from constipation, recurrent vomiting and failure to thrive, family history of recurrent pancreatitis without mutations in the PRSS1 and SPINK1 genes. Both ST and fecal elastase were altered although no CFTR gene mutations were found. Due to rapid clinical deterioration, celiac disease was suspected and diagnosed by laboratory tests and intestinal biopsy. After 2 weeks of gluten-free diet ST and fecal elastase normalized. Case 2: 14 months old male suffering from bilateral renal dysplasia, episodes of metabolic alkalosis, recurrent respiratory infections and recurrent vomiting. The child had more ST positives, but no CFTR mutations were found. During follow-up, he developed sensorineural hearing loss and an atrial septic defect was found. Finally, a diagnosis of Klinefelter was made, but the ST normalized several years later. Case 3 and 4: Two boys with stubborn constipation and fecal occlusion treated with Poly Ethylene Glycol (PEG) with salts showed pathological ST. The test returned normal a few days after stopping treatment. CONCLUSIONS We hypotesized the possible causes of ST alteration in these conditions: in celiac disease it could be due to a transient dysregulation of the aquaporins, rapidly reversed by the diet; in Klinefelter, it may be due to stable pubertal hypoandrogenism; while, the PEG formulation itself contains salts that can temporarily alter ST.
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Affiliation(s)
- C Cimbalo
- Department of Translational Medical Sciences, Cystic Fibrosis Center, University Federico II, Naples, Italy.
| | - A Tosco
- Department of Translational Medical Sciences, Cystic Fibrosis Center, University Federico II, Naples, Italy
| | - V Terlizzi
- Department of Paediatric Medicine, Cystic Fibrosis Centre, Anna Meyer Children's University Hospital, Florence, Italy
| | - A Sepe
- Department of Translational Medical Sciences, Cystic Fibrosis Center, University Federico II, Naples, Italy
| | - A Castaldo
- Department of Translational Medical Sciences, Cystic Fibrosis Center, University Federico II, Naples, Italy
| | - L Salvadori
- Department of Translational Medical Sciences, Cystic Fibrosis Center, University Federico II, Naples, Italy
| | - V Raia
- Department of Translational Medical Sciences, Cystic Fibrosis Center, University Federico II, Naples, Italy
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Abstract
Cystic fibrosis (CF) is the most common fatal genetic disease of the Caucasian population. Sweat testing is the principal diagnostic test for CF, and it is used for the evaluation of infants with positive CF newborn screening (NBS) and in patients with clinical findings suggesting CF. This article describes the classical sweat test method in detail and also provides an overwiew of recent advances.
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Affiliation(s)
- Yasemin Gokdemir
- Department of Pediatric Pulmonology, Marmara University, Istanbul, Turkey
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Siddaiah R, Thau E, Graff G. Effect of topiramate on sweat chloride level while screening for cystic fibrosis. BMJ Case Rep 2018; 2018:bcr-2018-225697. [PMID: 30185452 DOI: 10.1136/bcr-2018-225697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cystic fibrosis is the most common life-limiting genetic condition in Caucasians caused by Cystic Fibrosis Transmembrane conductance Regulator (CFTR) gene mutations. Sweat chloride is the current gold standard for diagnosis where values >60 mmol/L are diagnostic and values >30 mmol/L are indeterminate. There is limited literature on the effect of medications on the sweat chloride values. We report a case of topiramate being responsible for false-positive testing which resulted in overutilisation of medical resources and psychosocial stress on the family. Topiramate should be considered during the interpretation of the gold standard testing as one of the cause of false-positive sweat tests.
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Affiliation(s)
- Roopa Siddaiah
- Department of Pediatrics, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Eve Thau
- Department of Pediatrics, St Christophers Hospital for Children, Philadelphia, USA
| | - Gavin Graff
- Department of Pediatrics, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
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Abstract
Life-threatening and benign drug reactions occur frequently in the skin, affecting 8 % of the general population and 2-3 % of all hospitalized patients, emphasizing the need for physicians to effectively recognize and manage patients with drug-induced eruptions. Neurologic medications represent a vast array of drug classes with cutaneous side effects. Approximately 7 % of the United States (US) adult population is affected by adult-onset neurological disorders, reflecting a large number of patients on neurologic drug therapies. This review elucidates the cutaneous reactions associated with medications approved by the US Food and Drug Administration (FDA) to treat the following neurologic pathologies: Alzheimer disease, amyotrophic lateral sclerosis, epilepsy, Huntington disease, migraine, multiple sclerosis, Parkinson disease, and pseudobulbar affect. A search of the literature was performed using the specific FDA-approved drug or drug classes in combination with the terms 'dermatologic,' 'cutaneous,' 'skin,' or 'rash.' Both PubMed and the Cochrane Database of Systematic Reviews were utilized, with side effects ranging from those cited in randomized controlled trials to case reports. It behooves neurologists, dermatologists, and primary care physicians to be aware of the recorded cutaneous adverse reactions and their severity for proper management and potential need to withdraw the offending medication.
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Affiliation(s)
| | | | - Sylvia Hsu
- Department of Dermatology, Baylor College of Medicine, Houston, TX, USA
| | - Joseph S Kass
- Department of Neurology, Baylor College of Medicine, 7200 Cambridge St., 9th Floor, Houston, TX, 77030, USA.
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Lee M, Vecchio-Pagán B, Sharma N, Waheed A, Li X, Raraigh KS, Robbins S, Han ST, Franca AL, Pellicore MJ, Evans TA, Arcara KM, Nguyen H, Luan S, Belchis D, Hertecant J, Zabner J, Sly WS, Cutting GR. Loss of carbonic anhydrase XII function in individuals with elevated sweat chloride concentration and pulmonary airway disease. Hum Mol Genet 2016; 25:1923-1933. [PMID: 26911677 DOI: 10.1093/hmg/ddw065] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 02/22/2016] [Indexed: 12/20/2022] Open
Abstract
Elevated sweat chloride levels, failure to thrive (FTT), and lung disease are characteristic features of cystic fibrosis (CF, OMIM #219700). Here we describe variants in CA12 encoding carbonic anhydrase XII in two pedigrees exhibiting CF-like phenotypes. Exome sequencing of a white American adult diagnosed with CF due to elevated sweat chloride, recurrent hyponatremia, infantile FTT and lung disease identified deleterious variants in each CA12 gene: c.908-1 G>A in a splice acceptor and a novel frameshift insertion c.859_860insACCT. In an unrelated consanguineous Omani family, two children with elevated sweat chloride, infantile FTT, and recurrent hyponatremia were homozygous for a novel missense variant (p.His121Gln). Deleterious CFTR variants were absent in both pedigrees. CA XII protein was localized apically in human bronchiolar epithelia and basolaterally in the reabsorptive duct of human sweat glands. Respiratory epithelial cell RNA from the adult proband revealed only aberrant CA12 transcripts and in vitro analysis showed greatly reduced CA XII protein. Studies of ion transport across respiratory epithelial cells in vivo and in culture revealed intact CFTR-mediated chloride transport in the adult proband. CA XII protein bearing either p.His121Gln or a previously identified p.Glu143Lys missense variant localized to the basolateral membranes of polarized Madin-Darby canine kidney (MDCK) cells, but enzyme activity was severely diminished when assayed at physiologic concentrations of extracellular chloride. Our findings indicate that loss of CA XII function should be considered in individuals without CFTR mutations who exhibit CF-like features in the sweat gland and lung.
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Affiliation(s)
- Melissa Lee
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Briana Vecchio-Pagán
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neeraj Sharma
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abdul Waheed
- Edward A. Doisy Department of Biochemistry, St. Louis University School of Medicine, St. Louis, MO, USA
| | - Xiaopeng Li
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Karen S Raraigh
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Robbins
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sangwoo T Han
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Arianna L Franca
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Pellicore
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Taylor A Evans
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kristin M Arcara
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hien Nguyen
- Edward A. Doisy Department of Biochemistry, St. Louis University School of Medicine, St. Louis, MO, USA
| | - Shan Luan
- Edward A. Doisy Department of Biochemistry, St. Louis University School of Medicine, St. Louis, MO, USA
| | - Deborah Belchis
- Department of Pathology, Johns Hopkins Hospital, Baltimore, MD, USA and
| | - Jozef Hertecant
- Tawam Hospital, United Arab Emirates University, Al Ain, UAE
| | - Joseph Zabner
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - William S Sly
- Edward A. Doisy Department of Biochemistry, St. Louis University School of Medicine, St. Louis, MO, USA
| | - Garry R Cutting
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA,
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Guglani L, Moir D, Jain A. Sweat chloride concentrations in children with Idiopathic Nephrotic Syndrome. Pediatr Pulmonol 2016; 51:49-52. [PMID: 26309139 DOI: 10.1002/ppul.23213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 02/14/2015] [Accepted: 03/30/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Idiopathic Nephrotic Syndrome (INS) has been believed to cause a false positive elevation of sweat chloride concentrations, as measured by the sweat test. METHODS Sweat tests were done for 11 children with acute onset INS at admission and again while they were in remission, with results being compared to normal historical controls. RESULTS The initial sweat chloride concentration for 10 patients was normal (mean16.7 ± 11.02 mmol/L) and 1 patient had inadequate collection. This latter patient and two others were excluded during follow-up because of diagnoses other than INS. Sweat test results for the eight INS patients during follow up remained unchanged when they were in remission (16.94 ± 7.88 mmol/L; P = 0.98; Wilcoxon Matched-Pairs Signed Rank Test). In comparing sweat chloride concentrations from INS patients to those from 20 historical control subjects, we found no significant differences (Mann-Whitney Test; initial vs. control P = 0.643; follow up vs. control P = 0.806). CONCLUSIONS INS does not cause a false positive sweat test. Further studies should be done to objectively assess the conditions that have been reported to affect sweat chloride concentrations.
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Affiliation(s)
- Lokesh Guglani
- Carman and Ann Adams Department of Pediatrics, Division of Pediatric Pulmonology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Devin Moir
- Carman and Ann Adams Department of Pediatrics, Division of Pediatric Pulmonology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
| | - Amrish Jain
- Carman and Ann Adams Department of Pediatrics, Division of Pediatric Nephrology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, Michigan
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Guglani L, Stabel D, Weiner DJ. False-Positive and False-Negative Sweat Tests: Systematic Review of the Evidence. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2015; 28:198-211. [DOI: 10.1089/ped.2015.0552] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Lokesh Guglani
- Division of Pulmonology Allergy/Immunology Cystic Fibrosis & Sleep (PACS), Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, CA
| | - Danelle Stabel
- Division of General Pediatrics, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Daniel J. Weiner
- Division of Allergy, Immunology and Pulmonology, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Exercise intolerance, malnutrition, abnormal sweat chloride levels, and two CFTR mutations: is it cystic fibrosis? J Pediatr Health Care 2015; 29:201-4. [PMID: 25060775 DOI: 10.1016/j.pedhc.2014.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 05/24/2014] [Accepted: 05/31/2014] [Indexed: 11/21/2022]
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