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Simpson N, Anderson R, Sassi F, Pitman A, Lewis P, Tu K, Lannin H. The cost-effectiveness of neonatal screening for cystic fibrosis: an analysis of alternative scenarios using a decision model. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2005; 3:8. [PMID: 16091139 PMCID: PMC1215498 DOI: 10.1186/1478-7547-3-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2004] [Accepted: 08/09/2005] [Indexed: 12/21/2022] Open
Abstract
Background The use of neonatal screening for cystic fibrosis is widely debated in the United Kingdom and elsewhere, but the evidence available to inform policy is limited. This paper explores the cost-effectiveness of adding screening for cystic fibrosis to an existing routine neonatal screening programme for congenital hypothyroidism and phenylketonuria, under alternative scenarios and assumptions. Methods The study is based on a decision model comparing screening to no screening in terms of a number of outcome measures, including diagnosis of cystic fibrosis, life-time treatment costs, life years and QALYs gained. The setting is a hypothetical UK health region without an existing neonatal screening programme for cystic fibrosis. Results Under initial assumptions, neonatal screening (using an immunoreactive trypsin/DNA two stage screening protocol) costs £5,387 per infant diagnosed, or £1.83 per infant screened (1998 costs). Neonatal screening for cystic fibrosis produces an incremental cost-effectiveness of £6,864 per QALY gained, in our base case scenario (an assumed benefit of a 6 month delay in the emergence of symptoms). A difference of 11 months or more in the emergence of symptoms (and mean survival) means neonatal screening is both less costly and produces better outcomes than no screening. Conclusion Neonatal screening is expensive as a method of diagnosis. Neonatal screening may be a cost-effective intervention if the hypothesised delays in the onset of symptoms are confirmed. Implementing both antenatal and neonatal screening would undermine potential economic benefits, since a reduction in the birth incidence of cystic fibrosis would reduce the cost-effectiveness of neonatal screening.
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Affiliation(s)
- Neil Simpson
- Department of Child Health, Newbridge Hill, Bath, BA1 3QE, UK
| | - Rob Anderson
- Peninsula Technology Assessment Group (PenTAG) & Institute for Health & Social Care Research, Peninsula Medical School, Universities of Exeter and Plymouth, Plymouth, PL6 8BU, UK
| | - Franco Sassi
- Department of Social Policy, The London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Alexandra Pitman
- LSE Health and Social Care, The London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Peter Lewis
- Department of Medical Sciences, University of Bath, Bath, BA2 2 BB, UK
| | - Karen Tu
- University of Toronto, Canada. Associate Scientist, Institute of Clinical Evaluative Sciences (ICES), G-214, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Heather Lannin
- LSE Health and Social Care, The London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
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Abstract
The treatment of interstitial lung disease in children depends on the nature of the underlying pathology. In approximately 50% of cases a specific aetiology can be found such as: chronic viral infection, an auto-immune process, sarcoidosis or alveolar proteinosis. In the remainder, the process is idiopathic and the pathological findings are based on the descriptive morphological features seen in the diagnostic lung biopsy. If a specific cause is found then targeted treatment with antivirals, steroids or other immunosuppressive agents is available. Alveolar proteinosis can be treated by bronchial lavage and GM-CSF. Idiopathic cases are treated primarily with intravenous pulsed methylprednisolone or oral prednisolone backed up hydroxychloroquine. Other immunosuppressive agents such as azathioprine, methotrexate or ciclosporin have been used successfully in individual patients. The prognosis is very variable and includes no response to any therapy, partial response with chronic long term morbidity, to virtually complete recovery. The overall mortality rate is 15%. There are no controlled therapeutic trials available because of the rarity of these conditions in childhood. Unlike in adult practice, no correlation has as yet been demonstrated between the initial pattern of chest x-ray change or the degree of pathological change on the lung biopsy and the clinical outcome. The recurrence rate within families is 1 in 8.
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Affiliation(s)
- R Dinwiddie
- Respiratory Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK.
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Kaditis AG, Phadke S, Dickman P, Webber S, Kurland G, Michaels MG. Mortality after pediatric lung transplantation: autopsies vs. clinical impression. Pediatr Pulmonol 2004; 37:413-8. [PMID: 15095324 DOI: 10.1002/ppul.20025] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Appreciable mortality accompanies pediatric lung and heart-lung transplantation. The objective of this investigation was to compare the clinical impression of causes of death with autopsy findings in all pediatric lung or heart lung transplant recipients who had an autopsy performed between 1985-2002 at the Children's Hospital of Pittsburgh. Medical records and autopsy findings were reviewed. Thirty recipients with autopsies had 33 transplant procedures: heart-lung (16), double lung (14), repeat lung (2), and repeat heart-lung (1). Perioperative deaths occurred in 8 children, most often precipitated by graft dysfunction. Early deaths (2 weeks-1 year) occurred in 12 children resulting from infection. Late deaths (greater than 1 year) occurred in 10 children. Bronchiolitis obliterans complicated by infection was the major cause of death in these recipients. An autopsy confirmed the clinical impression of cause of death in 29/30 and added significant supplemental information in 16 cases. Unsuspected factors contributing to death included donor lung abnormalities, concurrent infection, and cardiovascular disease. Postmortem examination remains a critical component to augment the understanding of causes of death following pediatric thoracic transplantation.
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Affiliation(s)
- Athanasios G Kaditis
- Department of Pediatrics, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Abstract
Patients with severe cystic fibrosis who face lung transplant proposal react in different ways to the offer of this potentially life prolonging therapy. Little is known about those patients who refused the operation. This article describes various behaviour patterns and reactions following the transplant proposal. The major reasons for refusal of lung transplantation are based on personal experiences and encounters and on psychological and medical considerations. Only a subgroup of patients sticks to the initial decision of refusing the operation. Other patients question their decision and fluctuate between refusal and acceptance. A third group of patients reverses the decision mostly as a result of a significant life event. The decision not to undergo lung transplantation needs to be viewed as a reversible one and in the context of extreme physical and psychological vulnerability on the part of the patients. Health professionals should recognise the potential for change, remain non-judgmental and flexible, and adjust their services to the respective circumstances.
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Affiliation(s)
- I Götz
- University Children's Hospital, Währinger Gürtel 18-20, Vienna 1090, Austria
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Vricella LA, Karamichalis JM, Ahmad S, Robbins RC, Whyte RI, Reitz BA. Lung and heart-lung transplantation in patients with end-stage cystic fibrosis: the Stanford experience. Ann Thorac Surg 2002; 74:13-7; discussion 17-8. [PMID: 12118744 DOI: 10.1016/s0003-4975(02)03634-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bilateral lung (BLTx) and heart-lung transplantation have gained wide acceptance as treatment of end-stage lung disease from cystic fibrosis. We reviewed our 13-year experience with thoracic transplantation for cystic fibrosis with an operative approach that favors use of cardiopulmonary bypass for BLTx. METHODS Sixty-four patients with cystic fibrosis underwent heart-lung transplantation (n = 22, 34.4%) or BLTx (n = 42, 65.6%) between 1988 and 2000. Mean age and weight at transplantation were 29 +/- 8 years and 51 +/- 11 kg, respectively. Mean follow-up for survivors was 4.4 +/- 3.6 years. Immunosuppression regimen included cyclosporine, tapered corticosteroids, azathioprine, and induction therapy with OKT3 (murine monoclonal antibodies) or rabbit antithymocyte globulin. Cardiopulmonary bypass was used in all but 5 patients (7.8%). However, in 8 (19%) of the 42 patients having BLTx, only the grafting of the second lung was performed with cardiopulmonary bypass. RESULTS The operative mortality rate was 1.6%. The actuarial survival rates at 1 year, 3 years, 5 years and 10 years were 93.2%, 77.7%, 61.8%, and 48.1%, respectively, with no significant difference between BLTx and heart-lung transplantation. The major hospital complications were pneumonia (n = 11, 17.2%) and bleeding (n = 8, 12.5%). Clinically significant reperfusion injury was observed in 6 patients, 3 of whom required reintubation. Freedom from acute lung rejection beyond 1 year was 47.7%. One patient underwent late retransplantation, and 4 required bronchial stenting. Obliterative bronchiolitis accounted for eight (50.0%) of 16 late deaths. CONCLUSIONS Though postoperative bleeding and pneumonia are still of concern, satisfactory early and intermediate-term results can be expected in patients undergoing BLTx or heart-lung transplantation for cystic fibrosis. Cardiopulmonary bypass can be used for BLTx with no adverse impact on intermediate and long-term outcomes.
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Affiliation(s)
- Luca A Vricella
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California 94305-5407, USA.
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6
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Dinwiddie R, Sharief N, Crawford O. Idiopathic interstitial pneumonitis in children: a national survey in the United Kingdom and Ireland. Pediatr Pulmonol 2002; 34:23-9. [PMID: 12112793 DOI: 10.1002/ppul.10125] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Interstitial lung disease (ILD) of unknown etiology in immunocompetent patients is rare in children. A national survey was carried out in the United Kingdom and Ireland over a 3-year period in order to identify prevalence, age distribution, histopathology, natural history of the illness, and response to current treatment.Forty-six cases were identified, including 29 males and 17 females. Seventy-six percent presented in the first year of life. Nine (16%) occurred within four families. Conventional treatment with pulsed methylprednisolone, prednisolone, or hydroxychloroquine, singly or in combination, resulted in an excellent response in 65% of cases. Seven children died (15%). The recurrence risk for further children within the same family to develop ILD is estimated to be approximately 10%. The prevalence rate of this condition in the United Kingdom and Ireland during the period of study for children aged 0-16 years is estimated to be 3.6 cases/million.
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Affiliation(s)
- R Dinwiddie
- Respiratory Unit, Great Ormond Street Hospital for Children, London, UK.
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Estenne M, Maurer JR, Boehler A, Egan JJ, Frost A, Hertz M, Mallory GB, Snell GI, Yousem S. Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria. J Heart Lung Transplant 2002; 21:297-310. [PMID: 11897517 DOI: 10.1016/s1053-2498(02)00398-4] [Citation(s) in RCA: 949] [Impact Index Per Article: 43.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Abstract
Lung transplantation has been available as a therapeutic option for patients with end-stage cystic fibrosis lung disease for over 15 years, but the outcome following transplantation remains poor, and the supply of organs limited. For this reason some children opt to continue with medical treatment followed by terminal care rather than undergo transplantation. This article summarizes the current status of lung transplantation, including current referral guidelines and contraindications and also addresses current practice in terminal care.
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Affiliation(s)
- P Aurora
- Department of Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Trust, London, UK.
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9
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Gaynor JW, Bridges ND, Spray TL. Congenital Heart Surgery Nomenclature and Database Project: end-stage lung disease. Ann Thorac Surg 2000; 69:S343-57. [PMID: 10798440 DOI: 10.1016/s0003-4975(99)01251-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The extant nomenclature for end-stage lung disease is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories, using synonyms where appropriate. Indications for lung transplantation are coded under a broad category called pulmonary failure. The proposed hierarchical scheme also allows classification of complications of lung transplantation under a category called status post lung transplant. A comprehensive database set is presented which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail, which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented, which will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.
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Affiliation(s)
- J W Gaynor
- Division of Pediatric Cardiothoracic Surgery, The Cardiac Center at The Children's Hospital of Philadelphia, Pennsylvania 19104, USA.
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10
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Abstract
The psychosocial outcome of 23 heart and 21 heart-lung transplant recipients, aged 5-17 yrs, was determined and compared with the psychosocial outcome of a group of 46 children and adolescents who underwent conventional cardiac surgery. Preoperatively, and 12 months post-operatively, the patients' physical health status, mental state (ICD-9) and level of psychosocial functioning (GAF scale, DSM-IIIR) were assessed. There was an improvement in physical health in all groups. Preoperatively, psychiatric disorder, including anxiety and phobic states, depression and adjustment reaction, was noted in 6/23 (26%) children assessed for heart transplantation, 6/21 (28.5%) children assessed for heart-lung transplantation, and 12/46 (26%) children undergoing conventional cardiac surgery. The prevalence of psychiatric disorder remained in the transplant group but decreased in the non-transplant comparison group (6.5%). Improvement in overall levels of psychosocial functioning were found in all groups, but over 40% of all the participants were still functioning below normal levels. In summary, children with end-stage cardio-respiratory disease benefit physically and psychologically from heart or heart-lung transplantation treatment but there is a need for systematic psychosocial support both before and after transplantation.
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Affiliation(s)
- E Serrano-Ikkos
- Department of Psychological Medicine, Great Ormond Street Hospital, London, UK
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Minkes RK, Langer JC, Skinner MA, Foglia RP, O'Hagan A, Cohen AH, Mallory GB, Huddleston CB, Mendeloff EN. Intestinal obstruction after lung transplantation in children with cystic fibrosis. J Pediatr Surg 1999; 34:1489-93. [PMID: 10549754 DOI: 10.1016/s0022-3468(99)90110-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND/PURPOSE Distal intestinal obstruction syndrome (DIOS) occurs in 15% of patients with cystic fibrosis (CF). The authors reviewed their experience to determine the incidence, risk factors, and natural history of adhesive intestinal obstruction and DIOS after lung transplantation. METHODS Eighty-three bilateral transplants were performed in 70 CF patients between January 1990 and September 1998. All were on pancreatic enzymes preoperatively, and none had preoperative bowel preparation. Fifty-six patients (80%) had prior gastrostomy (n = 54) or jejunostomy (n = 2). Eighteen patients (25.7%) had a previous laparotomy for meconium ileus (n = 8), fundoplication (n = 4), liver transplant (n = 1), jejunal atresia (n = 1), Janeway gastrostomy takedown (n = 1), pyloromyotomy (n = 1), free air (n = 1), or appendectomy (n = 1). RESULTS After lung transplantation, 7 patients (10%) required laparotomy for bowel obstruction (6 during the same hospitalization, and 1 during a subsequent hospitalization). The causes of obstruction were adhesions only (n = 1), DIOS only (n = 2), and a combination of DIOS and adhesions (n = 4). Adhesiolysis was performed in the 5 patients with adhesions, and a small bowel resection was also performed in 1 patient. DIOS was treated by milking secretions distally without an enterotomy (n = 3) with an enterotomy and primary closure (n = 1) or with an end ileostomy and mucus fistula (n = 2). Five had recurrent DIOS early postoperatively. One resolved with intestinal lavage, 2 were treated successfully with hypaque disimpaction, and 2 underwent reoperation; 1 required an ileostomy. The most important risk factor for posttransplant obstruction was a previous major abdominal operation. Obstruction occurred in 7 of 18 (39%) who had undergone a prior laparotomy versus 0 of 52 who had not (P < .001, chi2). CONCLUSIONS (1) The incidence of intestinal obstruction is high after lung transplantation in children with CF. (2) Previous laparotomy is a significant risk factor. (3) Recurrent obstruction after surgery for this condition is common. (4) Preventive measures such as pretransplant bowel preparation and early postoperative bowel lavage may be beneficial in these patients.
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Affiliation(s)
- R K Minkes
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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12
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Affiliation(s)
- B J Rosenstein
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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13
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Götz I, Labenbacher I, Eichler I, Wojnarowski C, Götz M. Health-independent lung transplantation information of parents of children with cystic fibrosis. Transplantation 1997; 64:742-7. [PMID: 9311713 DOI: 10.1097/00007890-199709150-00014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Twenty-one to 63% of patients with cystic fibrosis (CF) accepted for lung and heart-lung transplantation die on the waiting list. A significant delay between referral and assessment may present an unrecognized hazard toward mortality. METHODS All parents of children with CF aged 3 to 15 years enrolled in the Vienna CF center were sent questionnaires to investigate their attitudes toward provision of information on lung transplantation (LT). RESULTS Complete questionnaires were obtained from 59 mothers and 47 fathers of 60 children. Thinking of LT evoked anxiety among 88% of parents, yet 54% wanted to get information at the present time. Parents younger than 30 years and older than 40 years were most interested in obtaining information. Recommendations for the clinicians showed preference for early over health deterioration-induced information (58% vs. 42%). The predominant fears associated with LT were the risk of dying (91%), physical pain (90%), and graft rejection (80%). First information on LT should be presented by the usual CF physician (96%) in the form of a face-to-face conversation (97%) and in the absence of the child (77%). Among the desired content areas, information about the chances LT offers had highest priority (86%). Thorough explanation of the rationale behind the transplant proposal (81%) and details of the whole procedure were requested. If their child were to actually need a transplant, many parents would rely on the doctor's assistance in jointly talking to the child (64%). The most helpful interventions for decision-making included meetings with successfully transplanted individuals (84%) and repeated discussions with experts. CONCLUSIONS Information may be implemented in medical care as a preventive strategy to avoid dangerous delays in case of unexpected turns toward the need for LT. A policy of recognition and acceptance of parental reluctance is mandatory.
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Affiliation(s)
- I Götz
- University Children's Hospital, Vienna, Austria
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Balfour-Lynn IM, Ryley HC, Whitehead BF. Subdural empyema due to Burkholderia cepacia: an unusual complication after lung transplantation for cystic fibrosis. J R Soc Med 1997; 90 Suppl 31:59-64. [PMID: 9204013 PMCID: PMC1296100 DOI: 10.1177/014107689709031s11] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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