1
|
Farrell PM. Why cystic fibrosis newborn screening programs have failed to meet original expectations… thus far. Mol Genet Metab 2023; 140:107679. [PMID: 37573205 DOI: 10.1016/j.ymgme.2023.107679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/14/2023]
Abstract
This Commentary summarizes what the author has learned in 46 years of research on newborn screening (NBS) for cystic fibrosis (CF) combined with healthcare and public health practice. The original expectation was that screening for this relatively common, life-threatening genetic disorder would lead to consistently timely diagnoses in the neonatal period and be equitable. Unfortunately, this ambitious goal has not been achieved in the USA despite the availability of an excellent, although imperfect, 2-tiered screening test employing immunoreactive trypsinogen (IRT) and DNA analysis for pathogenic variants in the gene that encodes the cystic fibrosis transmembrane conductance regulator (CFTR). In fact, variations in the quality of NBS programs, inconsistencies in their operations, and disparities in outcomes have been prominent features. The causes include leadership challenges and deficiencies among both CF centers and NBS labs; failures to form effective partnerships among CF centers and with NBS programs; relatively rapid implementation after 2005 with variable quality planning; misunderstandings and erroneous dogma about CF; data limitations regarding IRT, especially cutoff values, and CFTR genetics; tolerance of suboptimal protocols and false negative results; problems in dried blood spot collections plus a lack of transparency and national oversight; partial lack of readiness, qualifications, funding and/or willingness to innovate with floating IRT cutoffs and DNA/CFTR analyses; follow up challenges/deficiencies impairing timeliness, including sweat testing limitations; and published guidelines that are more descriptive than sufficiently critical and directive. But the lessons learned through uniquely intensive CF NBS research have been enlightening and guided the U.S. Cystic Fibrosis Foundation to nationwide quality improvement initiatives.
Collapse
Affiliation(s)
- Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Clinical Sciences Center (K4/948), Madison, WI 53792, USA.
| |
Collapse
|
2
|
Rehani MR, Marcus MS, Harris AB, Farrell PM, Ren CL. Variation in cystic fibrosis newborn screening algorithms in the United States. Pediatr Pulmonol 2023; 58:927-933. [PMID: 36507555 DOI: 10.1002/ppul.26279] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
RATIONALE Cystic fibrosis (CF) newborn screening (NBS) algorithms in the United States vary by state. Differences in CF NBS algorithms could potentially affect the detection rate of CF newborns and lead to disparities in CF diagnosis amongst different racial and ethnic groups. OBJECTIVES Generate a database of CF NBS algorithms in the United States and identify processes that may potentially lead to missed diagnoses or lead to healthcare disparities. METHODS We sent an online survey to state and regional CF and NBS leaders about the type and threshold of immunoreactive trypsinogen (IRT) cutoff used and methods used for CFTR gene variant analysis. Follow-up by email and phone was done to ensure a response from every state, clarify responses, and resolve discordances. RESULTS There is wide variation in the NBS algorithms employed by different states. Approximately half the states use a floating IRT cutoff, and half use a fixed IRT cutoff. CFTR variant analysis also varies widely, with two states analyzing only for the F508del variant and four states incorporating CFTR gene sequencing. The other states use CFTR variant panels ranging from 23 to 365 CFTR variants. CONCLUSIONS CF NBS algorithms vary widely amongst the different states in the United States, which affects the ability of CF NBS to diagnose newborn infants with CF consistently and uniformly across the country and potentially may miss more infants with CF from minority populations. Our results identify an important area for quality improvement in CF NBS.
Collapse
Affiliation(s)
- Maryann R Rehani
- Milken Institute of Public Health, George Washington University, Washington, District of Columbia, USA.,Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Mary S Marcus
- Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Anne B Harris
- Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Philip M Farrell
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Clement L Ren
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Martiniano SL, Croak K, Bonn G, Sontag MK, Sagel SD. Improving outcomes for Colorado's IRT-IRT-DNA cystic fibrosis newborn screening algorithm by implementing floating cutoffs. Mol Genet Metab 2021; 134:65-67. [PMID: 34489170 DOI: 10.1016/j.ymgme.2021.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/05/2021] [Accepted: 08/11/2021] [Indexed: 11/20/2022]
Abstract
The Colorado Newborn Screening Program (CO-NBS) screens for cystic fibrosis (CF) by measuring immunoreactive trypsinogen (IRT) from two screens coupled with DNA analysis (IRT/IRT/DNA). The Colorado CF Care Center identified 8 missed CF cases among 358,187 infants screened by the CO-NSP since 2016. Retrospective analysis of CO-NSP IRT data shows that a 96th percentile floating IRT cutoff with a 50 ng/mL fixed cutoff on the first screen, and second screen 50 ng/mL fixed cutoff would have identified 7 of the 8 missed cases. These efforts demonstrate the importance of continuous quality improvement in order to increase sensitivity and reduce missed cases.
Collapse
Affiliation(s)
- Stacey L Martiniano
- University of Colorado Anschutz Medical Center, United States; Children's Hospital Colorado, United States.
| | - Kendra Croak
- Colorado Department of Public Health & Environment, United States
| | - Gregory Bonn
- Colorado Department of Public Health & Environment, United States
| | - Marci K Sontag
- Center for Public Health Innovation at CI International, United States
| | - Scott D Sagel
- University of Colorado Anschutz Medical Center, United States; Children's Hospital Colorado, United States
| |
Collapse
|
4
|
Luo J, Ren Q, Liu W, Li X, Hong Yin, Song M, Bo Zhao, Guan G, Luo J, Liu G. Micropathogen community identification in ticks (Acari: Ixodidae) using third-generation sequencing. INTERNATIONAL JOURNAL FOR PARASITOLOGY-PARASITES AND WILDLIFE 2021; 15:238-248. [PMID: 34258218 PMCID: PMC8253887 DOI: 10.1016/j.ijppaw.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022]
Abstract
Ticks are important vectors that facilitate the transmission of a broad range of micropathogens to vertebrates, including humans. Because of their role in disease transmission, it has become increasingly important to identify and characterize the micropathogen profiles of tick populations. The objective of the present study was to survey the micropathogens of ticks by third-generation metagenomic sequencing using the PacBio Sequel platform. Approximately 46.481 Gbp of raw micropathogen sequence data were obtained from samples from four different regions of Heilongjiang Province, China. The clean consensus sequences were compared with host sequences and filtered at 90% similarity. Most of the identified genomes represent previously unsequenced strains. The draft genomes contain an average of 397,746 proteins predicted to be associated with micropathogens, over 30% of which do not have an adequate match in public databases. In these data, Anaplasma phagocytophilum and Coxiella burnetii were detected in all samples, while Borrelia burgdorferi was detected only in Ixodes persulcatus ticks from G1 samples. Viruses are a key component of micropathogen populations. In the present study, Simian foamy virus, Pustyn virus and Crimean-Congo haemorrhagic fever orthonairovirus were detected in different samples, and more than 10–30% of the viral community in all samples comprised unknown viruses. Deep metagenomic shotgun sequencing has emerged as a powerful tool to investigate the composition and function of complex microbial communities. Thus, our dataset substantially improves the coverage of tick micropathogen genomes in public databases and represents a valuable resource for micropathogen discovery and for studies of tick-borne diseases. The microbial communities from ticks were analysed by third-generation metagenomic sequencing using the PacBio Sequel platform. In these data, Anaplasma phagocytophilum and Coxiella burnetii were found in four groups, and Borrelia burgdorferi was detected only in Ixodes persulcatus ticks from G1 samples. Viruses are a key component of the composition of micropathogens. The third-generation metagenomic sequencing is far superior to second-generation sequencing in genome sequence integrity, and the similarity of the sequences obtained via third-generation metagenomic sequencing for discrimination is unmatched by other sequencing methods. Thus, our dataset substantially improves the coverage of tick micropathogen genomes in public databases and represents a valuable resource for micropathogen discovery and for studies of tick-borne diseases.
Collapse
Affiliation(s)
- Jin Luo
- State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Science, Xujiaping 1, Lanzhou, Gansu, 730046, PR China.,MOE Joint International Research Laboratory of Animal Health and Food Safety, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, 210095, PR China
| | - Qiaoyun Ren
- State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Science, Xujiaping 1, Lanzhou, Gansu, 730046, PR China
| | - Wenge Liu
- State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Science, Xujiaping 1, Lanzhou, Gansu, 730046, PR China
| | - Xiangrui Li
- MOE Joint International Research Laboratory of Animal Health and Food Safety, College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, 210095, PR China
| | - Hong Yin
- State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Science, Xujiaping 1, Lanzhou, Gansu, 730046, PR China.,Jiangsu Co-Innovation Center for the Prevention and Control of Important Animal Infectious Disease and Zoonoses, Yangzhou University, Yangzhou, 225009, PR China
| | - Mingxin Song
- Heilongjiang Provincial Key Laboratory of Animal-borne Zoonosis/Northeast Agriculture University, Harbin, 150030, PR China
| | - Bo Zhao
- Gansu Agriculture Technology College, Duanjiatan 425, Lanzhou, 730030, PR China
| | - Guiquan Guan
- State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Science, Xujiaping 1, Lanzhou, Gansu, 730046, PR China
| | - Jianxun Luo
- State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Science, Xujiaping 1, Lanzhou, Gansu, 730046, PR China
| | - Guangyuan Liu
- State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Veterinary Parasitology of Gansu Province, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Science, Xujiaping 1, Lanzhou, Gansu, 730046, PR China
| |
Collapse
|
5
|
Botti M, Terlizzi V, Francalanci M, Dolce D, Cavicchi MC, Neri AS, Galici V, Mergni G, Zavataro L, Centrone C, Festini F, Taccetti G. Cystic fibrosis in Tuscany: evolution of newborn screening strategies over time to the present. Ital J Pediatr 2021; 47:2. [PMID: 33407736 PMCID: PMC7788805 DOI: 10.1186/s13052-020-00948-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cystic fibrosis (CF) is a life-threatening disease affecting about 1:3000 newborns in Caucasian populations. The introduction of newborn screening for cystic fibrosis (CF NBS) has improved the clinical outcomes of individuals with CF through early diagnosis and early treatment. NBS strategies have been implemented over time. CF NBS was introduced extensively in 1984 in Tuscany, a region with 3.7 million people, characterized by a high allelic heterogeneity of CFTR gene. AIM AND METHODS The aim of the study is to present the results from 34 years (1984-2018) of CF NBS, retrospectively evaluating the sensitivity, specificity and predictive values of the tests. In particular, we studied the impact of the introduction of DNA molecular analysis in NBS in a region with high allelic heterogeneity, such as Tuscany. RESULTS Over these 34 years, 919,520 neonates were screened, using four different NBS strategies. From 1984 to 1991, CF NBS was performed by the determination of albumin on dried meconium (sensitivity 68.75%; specificity 99.82%). Subsequently, the analysis of immunoreactive trypsinogen on a blood spot was adopted as CF NBS protocol (sensitivity 83.33%; specificity 99.77%). From 1992 to 2010, this strategy was associated with lactase meconium dosage: IRT1/IRT2 + LACT protocol (sensitivity 87.50%; specificity 99.82%). From 2011, when the existing algorithm was integrated by analysis of CF causing variants of the CFTR gene (IRT1/IRT2 + LACT + IRT1/DNA protocol), a substantial improvement in sensitivity was seen (senisitivity 96.15%; specificity 99.75%). Other improved parameters with DNA analysis in the NBS programme, compared with the previous method, were the diagnosis time (52 days vs. 38 days) and the recall rate (0.58 to 0.38%). CONCLUSION The inclusion of DNA analysis in the NBS was a fundamental step in improving sensitivity, even in a region with high allelic variability.
Collapse
Affiliation(s)
- Matteo Botti
- Tuscany Support Cystic Fibrosis Service, Department of Pediatrics, Leghorn Hospital, Leghorn, Italy
| | - Vito Terlizzi
- Tuscany Referral Cystic Fibrosis Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Michela Francalanci
- Tuscany Referral Cystic Fibrosis Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Daniela Dolce
- Tuscany Referral Cystic Fibrosis Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Maria Chiara Cavicchi
- Tuscany Referral Cystic Fibrosis Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Anna Silvia Neri
- Tuscany Referral Cystic Fibrosis Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Valeria Galici
- Tuscany Referral Cystic Fibrosis Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Gianfranco Mergni
- Tuscany Referral Cystic Fibrosis Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Lucia Zavataro
- Tuscany Referral Cystic Fibrosis Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Claudia Centrone
- Diagnostic Genetics Unit, Careggi University Hospital, Florence, Italy
| | - Filippo Festini
- Department of Pediatrics, Anna Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Giovanni Taccetti
- Tuscany Referral Cystic Fibrosis Center, Anna Meyer Children's Hospital, Florence, Italy.
| |
Collapse
|
6
|
Farrell PM, Rock MJ, Baker MW. The Impact of the CFTR Gene Discovery on Cystic Fibrosis Diagnosis, Counseling, and Preventive Therapy. Genes (Basel) 2020; 11:E401. [PMID: 32276344 PMCID: PMC7231248 DOI: 10.3390/genes11040401] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 12/21/2022] Open
Abstract
Discovery of the cystic fibrosis transmembrane conductance regulator (CFTR) gene was the long-awaited scientific advance that dramatically improved the diagnosis and treatment of cystic fibrosis (CF). The combination of a first-tier biomarker, immunoreactive trypsinogen (IRT), and, if high, DNA analysis for CF-causing variants, has enabled regions where CF is prevalent to screen neonates and achieve diagnoses within 1-2 weeks of birth when most patients are asymptomatic. In addition, IRT/DNA (CFTR) screening protocols simultaneously contribute important genetic data to determine genotype, prognosticate, and plan preventive therapies such as CFTR modulator selection. As the genomics era proceeds with affordable biotechnologies, the potential added value of whole genome sequencing will probably enhance personalized, precision care that can begin during infancy. Issues remain, however, about the optimal size of CFTR panels in genetically diverse regions and how best to deal with incidental findings. Because prospects for a primary DNA screening test are on the horizon, the debate about detecting heterozygote carriers will likely intensify, especially as we learn more about this relatively common genotype. Perhaps, at that time, concerns about CF heterozygote carrier detection will subside, and it will become recognized as beneficial. We share new perspectives on that issue in this article.
Collapse
Affiliation(s)
- Philip M. Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 600 Highland Madison, WI 53792, USA
| | - Michael J. Rock
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA; (M.J.R.)
| | - Mei W. Baker
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792, USA; (M.J.R.)
- Newborn Screening Laboratory, Wisconsin State Laboratory of Hygiene, University of Wisconsin–Madison, 465 Henry Mall, Madison, WI 53706, USA
| |
Collapse
|
7
|
BAŞARAN AE, BAŞARAN A, KOCACIK UYGUN DF, ALPER Ö, ACICAN D, BİNGÖL A. Initial regional evaluation of the Cystic Fibrosis Newborn Screening Program: data from
the Mediterranean coast of Turkey. Turk J Med Sci 2019; 49:1655-1661. [PMID: 31655510 PMCID: PMC7518656 DOI: 10.3906/sag-1904-198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 09/28/2019] [Indexed: 12/22/2022] Open
Abstract
Background/ aim Since January 2015, the Cystic Fibrosis Newborn Screening (CFNS) program has been implemented in Turkey. We aimed to evaluate the demographic, clinical, and laboratory data of cases referred from the CFNS program and to determine the most suitable cut-off value for immunoreactive trypsinogen (IRT)-1 and immunoreactive trypsinogen (IRT-2) that are used in the CFNS program in Turkey. Materials and methods A total of 156 Turkish Caucasian subjects were determined as positive cases during 3 years, from January 2015 to January 2018, and were referred to the pediatric pulmonology clinics of Akdeniz University Hospital, Antalya, Turkey, for the national CFNS program. The evaluation was made considering the IRT-1 and IRT-2 values, demographic characteristics, sweat test results, CFTR genotypes, and diagnoses. Results Nine patients were diagnosed with cystic fibrosis (CF). Eight were diagnosed with CF-related metabolic syndromes and three were determined to be CF carriers. The ratio of CF to CF-related metabolic syndrome was determined as 1.1:1. Considering the limits of the present CFNS program and the IRT method, the positive predictive value (PPV) for the referred cases was determined as 5.8%. When a cut-off value of 105.6 ng/mL was taken for IRT-1, sensitivity was 100%, specificity was 59%, and PPV was 12.8%. For a cut-off value of 88.75 ng/mL for IRT-2, sensitivity was determined as 90%, specificity as 65%, and PPV as 15.2%. Conclusion This is the first detailed clinical study to evaluate the data from the CFNS program along the Mediterranean coast of Turkey. As false positive results are extremely high in Turkey, there is an urgent need for revision of the IRT-1 and IRT-2 limits by evaluating the data of the whole country.
Collapse
Affiliation(s)
- Abdurrahman Erdem BAŞARAN
- Department of Pediatrics, Division of Pulmonology, Faculty of Medicine, Akdeniz University, AntalyaTurkey
- Department of Pediatrics, Division of Pulmonology, University of Health Sciences Antalya Training and Research Hospital, AntalyaTurkey
| | - Ayşen BAŞARAN
- Department of Pediatrics, Division of Pulmonology, Faculty of Medicine, Akdeniz University, AntalyaTurkey
| | - Dilara Fatma KOCACIK UYGUN
- Department of Pediatrics, Division of Allergy Immunology, Faculty of Medicine, Akdeniz University, AntalyaTurkey
| | - Özgül ALPER
- Department of Medical Biology and Genetics, Faculty of Medicine, Akdeniz University, AntalyaTurkey
| | - Deniz ACICAN
- Department of Child and Adolescent Health, Public Health General Directorate, AnkaraTurkey
| | - Ayşen BİNGÖL
- Department of Pediatrics, Division of Pulmonology, Faculty of Medicine, Akdeniz University, AntalyaTurkey
- Department of Pediatrics, Division of Allergy Immunology, Faculty of Medicine, Akdeniz University, AntalyaTurkey
| |
Collapse
|
8
|
|
9
|
Farrell PM, White TB, Howenstine MS, Munck A, Parad RB, Rosenfeld M, Sommerburg O, Accurso FJ, Davies JC, Rock MJ, Sanders DB, Wilschanski M, Sermet-Gaudelus I, Blau H, Gartner S, McColley SA. Diagnosis of Cystic Fibrosis in Screened Populations. J Pediatr 2017; 181S:S33-S44.e2. [PMID: 28129810 DOI: 10.1016/j.jpeds.2016.09.065] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Cystic fibrosis (CF) can be difficult to diagnose, even when newborn screening (NBS) tests yield positive results. This challenge is exacerbated by the multitude of NBS protocols, misunderstandings about screening vs diagnostic tests, and the lack of guidelines for presumptive diagnoses. There is also confusion regarding the designation of age at diagnosis. STUDY DESIGN To improve diagnosis and achieve standardization in definitions worldwide, the CF Foundation convened a committee of 32 experts with a mission to develop clear and actionable consensus guidelines on diagnosis of CF with an emphasis on screened populations, especially the newborn population. A comprehensive literature review was performed with emphasis on relevant articles published during the past decade. RESULTS After reviewing the common screening protocols and outcome scenarios, 14 of 27 consensus statements were drafted that apply to screened populations. These were approved by 80% or more of the participants. CONCLUSIONS It is recommended that all diagnoses be established by demonstrating dysfunction of the CF transmembrane conductance regulator (CFTR) channel, initially with a sweat chloride test and, when needed, potentially with newer methods assessing membrane transport directly, such as intestinal current measurements. Even in babies with 2 CF-causing mutations detected via NBS, diagnosis must be confirmed by demonstrating CFTR dysfunction. The committee also recommends that the latest classifications identified in the Clinical and Functional Translation of CFTR project [http://www.cftr2.org/index.php] should be used to aid with CF diagnosis. Finally, to avoid delays in treatment, we provide guidelines for presumptive diagnoses and recommend how to determine the age of diagnosis.
Collapse
Affiliation(s)
- Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Michelle S Howenstine
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Anne Munck
- Centres de Ressources et de Compétences pour la Mucoviscidose, Hôpital Robert Debre, Paris, France
| | - Richard B Parad
- Department of Pediatric and Newborn Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | | | - Frank J Accurso
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jane C Davies
- Pediatric Respirology and Experimental Medicine, Imperial College London and Pediatric Respiratory Medicine, Royal Brompton and Harefield National Health Service Foundation Trust, London, United Kingdom
| | - Michael J Rock
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Don B Sanders
- Department of Pediatrics, Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Michael Wilschanski
- Pediatric Gastroenterology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Isabelle Sermet-Gaudelus
- Institut Necker Enfants Malades/INSERM U1151, Hôpital Necker Enfants Malades, Centres de Ressources et de Compétences pour la Mucoviscidose, Paris, France
| | - Hannah Blau
- Sackler Faculty of Medicine, Graub Cystic Fibrosis Center, Pulmonary Institute Schneider Children's Medical Center of Israel, Petah Tikva, Tel Aviv University, Tel Aviv, Israel
| | | | - Susanna A McColley
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
10
|
Sontag MK, Lee R, Wright D, Freedenberg D, Sagel SD. Improving the Sensitivity and Positive Predictive Value in a Cystic Fibrosis Newborn Screening Program Using a Repeat Immunoreactive Trypsinogen and Genetic Analysis. J Pediatr 2016; 175:150-158.e1. [PMID: 27131402 DOI: 10.1016/j.jpeds.2016.03.046] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 02/16/2016] [Accepted: 03/16/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the performance of a new cystic fibrosis (CF) newborn screening algorithm, comprised of immunoreactive trypsinogen (IRT) in first (24-48 hours of life) and second (7-14 days of life) dried blood spot plus DNA on second dried blood spot, over existing algorithms. STUDY DESIGN A retrospective review of the IRT/IRT/DNA algorithm implemented in Colorado, Wyoming, and Texas. RESULTS A total of 1 520 079 newborns were screened, 32 557 (2.1%) had abnormal first IRT; 8794 (0.54%) on second. Furthermore, 14 653 mutation analyses were performed; 1391 newborns were referred for diagnostic testing; 274 newborns were diagnosed; and 201/274 (73%) of newborns had 2 mutations on the newborn screening CFTR panel. Sensitivity was 96.2%, compared with sensitivity of 76.1% observed with IRT/IRT (105 ng/mL cut-offs, P < .0001). The ratio of newborns with CF to heterozygote carriers was 1:2.5, and newborns with CF to newborns with CFTR-related metabolic syndrome was 10.8:1. The overall positive predictive value was 20%. The median age of diagnosis was 28, 30, and 39.5 days in the 3 states. CONCLUSIONS IRT/IRT/DNA is more sensitive than IRT/IRT because of lower cut-offs (∼97 percentile or 60 ng/mL); higher cut-offs in IRT/IRT programs (>99 percentile, 105 ng/mL) would not achieve sufficient sensitivity. Carrier identification and identification of newborns with CFTR-related metabolic syndrome is less common in IRT/IRT/DNA compared with IRT/DNA. The time to diagnosis is nominally longer, but diagnosis can be achieved in the neonatal period and opportunities to further improve timeliness have been enacted. IRT/IRT/DNA algorithm should be considered by programs with 2 routine screens.
Collapse
Affiliation(s)
- Marci K Sontag
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO.
| | - Rachel Lee
- Laboratory Services Section, Texas Department of State Health Services, Austin, TX; Laboratory Services Division, Colorado Department of Public Health and Environment, Denver, CO
| | - Daniel Wright
- Laboratory Services Division, Colorado Department of Public Health and Environment, Denver, CO
| | - Debra Freedenberg
- Laboratory Services Section, Texas Department of State Health Services, Austin, TX
| | - Scott D Sagel
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| |
Collapse
|
11
|
Abstract
The diagnosis of cystic fibrosis (CF) has evolved over the past decade as newborn screening has become universal in the United States and elsewhere. The heterogeneity of phenotypes associated with CF transmembrane conductance regulator (CFTR) dysfunction and mutations in the CFTR gene has become clearer, ranging from classic pancreatic-insufficient CF to manifestations in only 1 organ system to indeterminate diagnoses identified by newborn screening. The tools available for diagnosis have also expanded. This article reviews the newest diagnostic criteria for CF, newborn screening, prenatal screening and diagnosis, and indeterminate diagnoses in newborn-screened infants and symptomatic adults.
Collapse
|
12
|
Newborn screening for cystic fibrosis. THE LANCET RESPIRATORY MEDICINE 2016; 4:653-661. [PMID: 27053341 DOI: 10.1016/s2213-2600(16)00053-9] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/23/2016] [Accepted: 01/28/2016] [Indexed: 01/16/2023]
Abstract
Since the late 1970s when the potential of the immunoreactive trypsinogen assay for early identification of infants with cystic fibrosis was first recognised, the performance of newborn blood spot screening (NBS) has been continually assessed and its use has gradually expanded. NBS for cystic fibrosis is a cost-effective strategy and, if standards of care are fully implemented and robust management pathways are in place, has a positive effect on clinical outcomes. In the past decade, NBS has undergone rapid expansion and an unprecedented number of infants with cystic fibrosis have access to early diagnosis and care. Cystic fibrosis NBS has now moved on from the development phase and is entering an era of consolidation. In the future, research should focus on the rationalisation and optimisation of existing programmes, with particular attention to bioethical implications such as unwanted detection of carriers and inconclusive diagnoses.
Collapse
|
13
|
|
14
|
Scully MA, Farrell PM, Ciafaloni E, Griggs RC, Kwon JM. Cystic fibrosis newborn screening: A model for neuromuscular disease screening? Ann Neurol 2014; 77:189-97. [DOI: 10.1002/ana.24316] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 10/10/2014] [Accepted: 11/17/2014] [Indexed: 01/06/2023]
Affiliation(s)
- Michele A. Scully
- Department of Neurology; University of Rochester Medical Center; Rochester NY
| | - Philip M. Farrell
- Department of Pediatrics; University of Wisconsin School of Medicine and Public Health; Madison WI
| | - Emma Ciafaloni
- Department of Neurology; University of Rochester Medical Center; Rochester NY
| | - Robert C. Griggs
- Department of Neurology; University of Rochester Medical Center; Rochester NY
| | - Jennifer M. Kwon
- Department of Neurology; University of Rochester Medical Center; Rochester NY
| |
Collapse
|
15
|
Nshimyumukiza L, Bois A, Daigneault P, Lands L, Laberge AM, Fournier D, Duplantie J, Giguère Y, Gekas J, Gagné C, Rousseau F, Reinharz D. Cost effectiveness of newborn screening for cystic fibrosis: A simulation study. J Cyst Fibros 2014; 13:267-74. [DOI: 10.1016/j.jcf.2013.10.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/21/2013] [Accepted: 10/22/2013] [Indexed: 10/26/2022]
|
16
|
Sommerburg O, Krulisova V, Hammermann J, Lindner M, Stahl M, Muckenthaler M, Kohlmueller D, Happich M, Kulozik AE, Votava F, Balascakova M, Skalicka V, Stopsack M, Gahr M, Macek M, Mall MA, Hoffmann GF. Comparison of different IRT-PAP protocols to screen newborns for cystic fibrosis in three central European populations. J Cyst Fibros 2013; 13:15-23. [PMID: 23891278 DOI: 10.1016/j.jcf.2013.06.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 06/10/2013] [Accepted: 06/19/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND In recent years different IRT/PAP protocols have been evaluated, but the individual performance remains unclear. To optimize the IRT/PAP strategy we compared protocols from three regional CF newborn screening centers (Heidelberg, Dresden, and Prague). METHODS We evaluated the effect of elevating the IRT-cut-off from 50 to 65 μg/l (~97.5th to ~99.0th percentile), the need of a failsafe protocol (FS, IRT ≥ 99.9th percentile) and the relative performance using either two IRT-dependent PAP-cut-offs or one PAP-cut-off. FINDINGS Elevation of the IRT cut-off to 65 μg/l (~99.0th percentile) increased the PPV significantly (Dresden: 0.065 vs. 0.080, p < 0.0001, Prague: 0.052 vs. 0.074, p < 0.0001) without reducing sensitivity. All three IRT/PAP protocols showed a trend towards a higher sensitivity with FS than without and when using one PAP-cut-off instead of two IRT-dependent PAP-cut-offs. CONCLUSIONS For best performance we suggest an IRT/PAP protocol with an IRT-cut-off close to the 99.0th percentile, FS, and a single PAP-cut-off.
Collapse
Affiliation(s)
- Olaf Sommerburg
- Division of Paediatric Pulmonology & Allergy and Cystic Fibrosis Center, Department of Paediatrics III, Children's Hospital, University of Heidelberg, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Im Neuenheimer Feld 350, D-69120 Heidelberg, Germany.
| | - Veronika Krulisova
- Department of Biology and Medical Genetics, University Hospital Motol and 2nd Faculty of Medicine, Charles University, V Uvalu 84, Prague 5, CZ 150 06, Czech Republic
| | - Jutta Hammermann
- Pediatric Department, University Hospital of Dresden, Fetscherstr. 74, D-01307 Dresden, Germany
| | - Martin Lindner
- Division of Metabolic Diseases and Newborn Screening Center, Department of Paediatrics I, Children's Hospital, University of Heidelberg, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany
| | - Mirjam Stahl
- Division of Paediatric Pulmonology & Allergy and Cystic Fibrosis Center, Department of Paediatrics III, Children's Hospital, University of Heidelberg, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Im Neuenheimer Feld 350, D-69120 Heidelberg, Germany
| | - Martina Muckenthaler
- Division of Paediatric Pulmonology & Allergy and Cystic Fibrosis Center, Department of Paediatrics III, Children's Hospital, University of Heidelberg, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Im Neuenheimer Feld 350, D-69120 Heidelberg, Germany
| | - Dirk Kohlmueller
- Division of Metabolic Diseases and Newborn Screening Center, Department of Paediatrics I, Children's Hospital, University of Heidelberg, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany
| | - Margit Happich
- Division of Paediatric Pulmonology & Allergy and Cystic Fibrosis Center, Department of Paediatrics III, Children's Hospital, University of Heidelberg, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany
| | - Andreas E Kulozik
- Division of Paediatric Pulmonology & Allergy and Cystic Fibrosis Center, Department of Paediatrics III, Children's Hospital, University of Heidelberg, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany
| | - Felix Votava
- Department of Pediatrics, University Hospital Kralovske Vinohrady and 3rd Faculty of Medicine, Charles University, Srobarova 50, Prague 10, CZ 100 34, Czech Republic
| | - Miroslava Balascakova
- Department of Biology and Medical Genetics, University Hospital Motol and 2nd Faculty of Medicine, Charles University, V Uvalu 84, Prague 5, CZ 150 06, Czech Republic
| | - Veronika Skalicka
- Department of Pediatrics, University Hospital Motol and 2nd Faculty of Medicine, Charles University, V Uvalu 84, Prague 5, CZ 100 06, Czech Republic
| | - Marina Stopsack
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital of Dresden, Fetscherstr. 74, D-01307 Dresden, Germany
| | - Manfred Gahr
- Pediatric Department, University Hospital of Dresden, Fetscherstr. 74, D-01307 Dresden, Germany
| | - Milan Macek
- Department of Biology and Medical Genetics, University Hospital Motol and 2nd Faculty of Medicine, Charles University, V Uvalu 84, Prague 5, CZ 150 06, Czech Republic
| | - Marcus A Mall
- Division of Paediatric Pulmonology & Allergy and Cystic Fibrosis Center, Department of Paediatrics III, Children's Hospital, University of Heidelberg, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany; Translational Lung Research Centre Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Im Neuenheimer Feld 350, D-69120 Heidelberg, Germany; Department of Translational Pulmonology, University of Heidelberg, Im Neuenheimer Feld 350, D-69120 Heidelberg, Germany
| | - Georg F Hoffmann
- Translational Lung Research Centre Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Im Neuenheimer Feld 350, D-69120 Heidelberg, Germany; Division of Metabolic Diseases and Newborn Screening Center, Department of Paediatrics I, Children's Hospital, University of Heidelberg, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany
| |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW Newborn screening for cystic fibrosis (CF) is now universal in the US and many other countries. The rapid expansion of screening has resulted in numerous publications identifying new challenges for healthcare providers. This review provides an overview of these publications and includes ideas on managing these challenges. RECENT FINDINGS Most CF newborn screening algorithms involve DNA mutation analysis. As screening has expanded, new challenges have been identified related to carrier detection and inconclusive diagnoses. Early descriptions of infants with CF-related metabolic syndrome (CRMS) indicate that the natural history of this condition cannot be predicted. Early identification has also provided an opportunity to better understand the pathophysiology of CF. However, few studies have been conducted in infants with CF to determine optimal therapy and recommendations are largely anecdotal. SUMMARY Newborn screening provides an opportunity to identify and begin treatment early in individuals with CF. Whereas a single, optimal approach to screening does not exist, all programs can benefit from new findings regarding sweat testing, carrier detection, early pathophysiology, and clinical outcomes.
Collapse
|
18
|
Abstract
Aquagenic wrinkling of the palms (AWP) is a condition characterized by excessive wrinkling, palmar edema, and whitish papules accompanied by pain, pruritus, or discomfort after brief immersion of the hands in water. It is well documented to be associated with cystic fibrosis (CF), with several theories regarding the pathogenesis having been proposed. We report a case of two sisters with AWP in whom CF has not been diagnosed and review the literature on AWP and its association with CF and CF carrier status. Because diagnosis of mild forms CF or knowledge of an underlying CF genetic mutation is frequently unknown, identification of AWP may represent the only sign of such mutations. The dermatologist plays an integral role in early detection of AWP, and the importance of genetic testing in such patients cannot be overlooked. We recommend various measures to apply in clinical practice to ensure diagnosis and decrease morbidity and mortality in patients.
Collapse
Affiliation(s)
- Ligaya Park
- University Hospitals Case Medical Center, Cleveland, Ohio, USA.
| | | | | |
Collapse
|
19
|
Therrell BL, Hannon WH, Hoffman G, Ojodu J, Farrell PM. Immunoreactive Trypsinogen (IRT) as a Biomarker for Cystic Fibrosis: challenges in newborn dried blood spot screening. Mol Genet Metab 2012; 106:1-6. [PMID: 22425451 DOI: 10.1016/j.ymgme.2012.02.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 02/21/2012] [Accepted: 02/21/2012] [Indexed: 11/22/2022]
Abstract
On May 23-24, 2011, a workshop entitled "Immunoreactive Trypsinogen (IRT) as a Biomarker for Cystic Fibrosis: Technical Issues and Challenges" was held in Annapolis, Maryland. The two-day workshop was co-hosted by the National Newborn Screening and Genetics Resource Center, Austin, Texas, and the Association of Public Health Laboratories, Silver Spring, Maryland, in collaboration with the Health Resources and Services Administration and the Centers for Disease Control and Prevention. Participants included nearly 40 representatives from U.S. state public health and commercial laboratories performing newborn dried blood spot screening tests for cystic fibrosis (CF), the federal government, academic research institutions, and commercial vendors of products used in newborn screening. Representatives from selected European CF newborn screening programs were also present. The workshop focused on identifying key IRT testing issues and mechanisms for achieving their resolution and laboratory harmonization in order to reduce, or eliminate completely, the late identified CF cases following a negative newborn screen. Informative findings are reported, their impacts on improving IRT screening are described, and their implications are discussed.
Collapse
Affiliation(s)
- Bradford L Therrell
- National Newborn Screening and Genetics Resource Center, 1912 West Anderson Lane, Suite 210, Austin, TX, USA.
| | | | | | | | | |
Collapse
|
20
|
Hwu WL, Chien YH, Lee NC, Wang SF, Chiang SC, Hsu LW. Application of Mass Spectrometry in Newborn Screening: About Both Small Molecular Diseases and Lysosomal Storage Diseases. CHEMICAL DIAGNOSTICS 2012; 336:177-96. [DOI: 10.1007/128_2012_354] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
21
|
|
22
|
Rock MJ, Sharp JK. Cystic fibrosis and CRMS screening: what the primary care pediatrician should know. Pediatr Ann 2010; 39:759-68. [PMID: 21162484 DOI: 10.3928/00485713-20101117-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
23
|
|
24
|
Current World Literature. Curr Opin Pulm Med 2010; 16:623-7. [DOI: 10.1097/mcp.0b013e32834006f9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|