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Maciel LMZ, Magalhães PKR, Ciampo IRLD, Sousa MLBD, Fernandes MIM, Sawamura R, Bittar RR, Molfetta GAD, Silva Júnior WAD. The first five-year evaluation of cystic fibrosis neonatal screening program in São Paulo State, Brazil. CAD SAUDE PUBLICA 2020; 36:e00049719. [PMID: 33111836 DOI: 10.1590/0102-311x00049719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/20/2020] [Indexed: 11/21/2022] Open
Abstract
The Hospital of the Ribeirão Preto Medical School, University of São Paulo is one of the three screening centers in São Paulo State, Brazil, and has included a test for cystic fibrosis (CF) since February 6, 2010, by a court order. We evaluated the first five years of this CF-newborn screening program. The original immunoreactive trypsinogen (IRT)/IRT screening protocol was adopted in Brazil. A total of 173,571 newborns were screened, 1,922 (1.1%) of whom showed IRT1 ≥ 70ng/mL. Of these, 1,795 (93.4%) collected IRT2, with elevated results (IRT2 ≥ 70ng/mL) in 102 of them (5.2%). We identified a total of 26 CF cases during this period, including three CF cases that were not detected by the CF-newborn screening. The incidence of the disease among the screened babies was 1:6,675 newborns screened. Median age at the initial evaluation was 42 days, comparable to that of neonates screened with the IRT/DNA protocol. Almost all infants with CF already exhibited some manifestations of the disease during the neonatal period. The mutation most frequently detected in the CF cases was F508del. These findings suggest the early age at the beginning of treatment at our center was due to the effort of the persons involved in the program regarding an effective active search. Considering the false negative results of CF-newborn screening and the early onset of clinical manifestations of the disease in this study, pediatricians should be aware of the diagnosis of CF even in children with negative test.
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Affiliation(s)
| | | | | | | | | | - Regina Sawamura
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brasil
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An Enzyme Immunoassay for Determining Immunoreactive Trypsinogen (IRT) in Dried Blood Spots on Filter Paper Using an Ultra-Microanalytical System. Appl Biochem Biotechnol 2018; 186:1034-1046. [DOI: 10.1007/s12010-018-2785-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/15/2018] [Indexed: 12/30/2022]
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Coffey MJ, Whitaker V, Gentin N, Junek R, Shalhoub C, Nightingale S, Hilton J, Wiley V, Wilcken B, Gaskin KJ, Ooi CY. Differences in Outcomes between Early and Late Diagnosis of Cystic Fibrosis in the Newborn Screening Era. J Pediatr 2017; 181:137-145.e1. [PMID: 27837951 DOI: 10.1016/j.jpeds.2016.10.045] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 09/07/2016] [Accepted: 10/12/2016] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To evaluate children with cystic fibrosis (CF) who had a late diagnosis of CF (LD-CF) despite newborn screening (NBS) and compare their clinical outcomes with children diagnosed after a positive NBS (NBS-CF). STUDY DESIGN A retrospective review of patients with LD-CF in New South Wales, Australia, from 1988 to 2010 was performed. LD-CF was defined as NBS-negative (negative immunoreactive trypsinogen or no F508del) or NBS-positive but discharged following sweat chloride < 60 mmol/L. Cases of LD-CF were each matched 1:2 with patients with NBS-CF for age, sex, hospital, and exocrine pancreatic status. RESULTS A total of 45 LD-CF cases were identified (39 NBS-negative and 6 NBS-positive) with 90 NBS-CF matched controls. Median age (IQR) of diagnosis for LD-CF and NBS-CF was 1.35 (0.4-2.8) and 0.12 (0.03-0.2) years, respectively (P <.0001). Estimated incidence of LD-CF was 1 in 45 000 live births. Compared with NBS-CF, LD-CF had more respiratory manifestations at time of diagnosis (66% vs 4%; P <.0001), a higher rate of hospital admission per year for respiratory illness (0.49 vs 0.2; P = .0004), worse lung function (forced expiratory volume in 1 second percentage of predicted, 0.88 vs 0.97; P = .007), and higher rates of chronic colonization with Pseudomonas aeruginosa (47% vs 24%; P = .01). The LD-CF cohort also appeared to be shorter than NBS-CF controls (mean height z-score -0.65 vs -0.03; P = .02). CONCLUSIONS LD-CF, despite NBS, seems to be associated with worse health before diagnosis and worse later growth and respiratory outcomes, thus providing further support for NBS programs for CF.
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Affiliation(s)
- Michael J Coffey
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Viola Whitaker
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Natalie Gentin
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia; Department of General Pediatrics, Sydney Children's Hospital Randwick, Sydney, Australia
| | - Rosie Junek
- The Children's Hospital at Westmead, Sydney, Australia
| | - Carolyn Shalhoub
- Department of Medical Genetics, Sydney Children's Hospital Randwick, Sydney, Australia
| | - Scott Nightingale
- GrowUpWell Priority Research Centre, University of Newcastle, Newcastle, Australia; Department of Gastroenterology, John Hunter Children's Hospital, Newcastle, Australia
| | - Jodi Hilton
- University of Newcastle, Newcastle, Australia; Department of Respiratory Medicine, John Hunter Children's Hospital, Newcastle, Australia
| | - Veronica Wiley
- The Children's Hospital at Westmead, Sydney, Australia; The University of Sydney, Sydney, Australia
| | - Bridget Wilcken
- The Children's Hospital at Westmead, Sydney, Australia; The University of Sydney, Sydney, Australia
| | - Kevin J Gaskin
- The Children's Hospital at Westmead, Sydney, Australia; The University of Sydney, Sydney, Australia
| | - Chee Y Ooi
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia; Department of Gastroenterology, Sydney Children's Hospital Randwick, Sydney, Australia.
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Prickett MH, Hauser AR, McColley SA, Cullina J, Potter E, Powers C, Jain M. Aminoglycoside resistance of Pseudomonas aeruginosa in cystic fibrosis results from convergent evolution in the mexZ gene. Thorax 2016; 72:40-47. [PMID: 27325751 DOI: 10.1136/thoraxjnl-2015-208027] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 05/10/2016] [Accepted: 05/24/2016] [Indexed: 01/17/2023]
Abstract
RATIONALE Aminoglycoside (AG) resistance of Pseudomonas aeruginosa in cystic fibrosis (CF) is associated with poorer clinical outcomes and is usually due to overexpression of the efflux pump MexXY. MexXY is regulated by mexZ, one of the most commonly mutated genes in CF P. aeruginosa isolates. Little is known about the evolutionary relationship between AG resistance, MexXY expression and mexZ mutations. OBJECTIVES To test the hypothesis that AG resistance in P. aeruginosa develops in parallel with higher MexXY expression and mexZ mutations. METHODS CF P. aeruginosa isolates were compared for chronically infected (CI) adults, CI children and children with new infection. MEASUREMENTS One P. aeruginosa isolate from each patient was analysed for mexZ mutations, mexY mRNA expression and amikacin resistance. MAIN RESULTS 56 patients with CF were enrolled: 21 children with new P. aeruginosa infection, 18 CI children and 17 CI adults. Amikacin resistance and mexY mRNA expression were higher in cohorts with longer P. aeruginosa infection. The prevalence of non-conservative mexZ mutations was 0%, 33% and 65% in children with new infection, CI children and CI adults, respectively. The same trend was seen in the ratio of non-conservative to non-synonymous mexZ mutations. Of isolates with non-conservative mexZ mutations, 59% were amikacin-resistant compared with 18% of isolates with non-synonymous mutations. The doubling rate of amikacin resistance and non-conservative mexZ mutations was approximately 5 years. CONCLUSIONS P. aeruginosa mexZ mutations undergo positive selection resulting in increased mexY mRNA expression and amikacin resistance and likely play a role in bacterial adaption in the CF lung.
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Affiliation(s)
- Michelle H Prickett
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alan R Hauser
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Susanna A McColley
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Joanne Cullina
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Eileen Potter
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Cathy Powers
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Manu Jain
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Cohen-Cymberknoh M, Shoseyov D, Kerem E. Managing cystic fibrosis: strategies that increase life expectancy and improve quality of life. Am J Respir Crit Care Med 2011; 183:1463-71. [PMID: 21330455 DOI: 10.1164/rccm.201009-1478ci] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The survival of patients with cystic fibrosis (CF) continues to improve. The discovery and cloning of the CFTR gene more than 21 years ago led to the identification of the structure and function of the CFTR chloride channel. New therapies based on the understanding of the function of CFTR are currently under development. The better clinical status and improved survival of patients with CF is not only a result of understanding of the molecular mechanisms of CF but also a result of the development of therapeutic strategies that are based on insights into the natural course of the disease. Current CF treatments that target respiratory infections, inflammation, mucociliary clearance, and nutritional status are associated with improved pulmonary function and reduced exacerbations. Patients benefit from treatment at a specialized CF center by a multidisciplinary dedicated team with emphasis being placed on frequent visits, periodic testing, and monitoring adherence to therapy. The purpose of this review is to survey recent developments in CF care that are responsible for the improved survival and quality of life of patients with CF.
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Affiliation(s)
- Malena Cohen-Cymberknoh
- Department of Pediatrics and CF Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Farrell PM, Rosenstein BJ, White TB, Accurso FJ, Castellani C, Cutting GR, Durie PR, Legrys VA, Massie J, Parad RB, Rock MJ, Campbell PW. Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report. J Pediatr 2008; 153:S4-S14. [PMID: 18639722 PMCID: PMC2810958 DOI: 10.1016/j.jpeds.2008.05.005] [Citation(s) in RCA: 671] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Newborn screening (NBS) for cystic fibrosis (CF) is increasingly being implemented and is soon likely to be in use throughout the United States, because early detection permits access to specialized medical care and improves outcomes. The diagnosis of CF is not always straightforward, however. The sweat chloride test remains the gold standard for CF diagnosis but does not always give a clear answer. Genotype analysis also does not always provide clarity; more than 1500 mutations have been identified in the CF transmembrane conductance regulator (CFTR) gene, not all of which result in CF. Harmful mutations in the gene can present as a spectrum of pathology ranging from sinusitis in adulthood to severe lung, pancreatic, or liver disease in infancy. Thus, CF identified postnatally must remain a clinical diagnosis. To provide guidance for the diagnosis of both infants with positive NBS results and older patients presenting with an indistinct clinical picture, the Cystic Fibrosis Foundation convened a meeting of experts in the field of CF diagnosis. Their recommendations, presented herein, involve a combination of clinical presentation, laboratory testing, and genetics to confirm a diagnosis of CF.
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Affiliation(s)
- Philip M. Farrell
- Department of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Frank J. Accurso
- Department of Pediatrics, University of Colorado Health Sciences Center, Denver, CO
| | | | - Garry R. Cutting
- Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD
| | - Peter R. Durie
- Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Vicky A. Legrys
- Department of Allied Health Sciences, University of North Carolina, Chapel Hill, NC
| | - John Massie
- Department of Respiratory Medicine, Royal Children’s Hospital, Melbourne, Australia
| | - Richard B. Parad
- Department of Newborn Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Michael J. Rock
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Lebo RV, Omlor GJ. Targeted extended cystic fibrosis mutation testing on known and at-risk patients and relatives. ACTA ACUST UNITED AC 2008; 11:427-44. [PMID: 18294061 DOI: 10.1089/gte.2007.0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This paper reports mathematically derived residual risks of being a carrier or being affected with cystic fibrosis following various screening scenarios to assist in interpreting test results and advising patients. While parental screening with 23 American College of Medical Genetics (ACMG) cystic fibrosis mutations defines the 64% of affected U.S. Caucasian fetuses with two detectable mutations, newborn screening for elevated immunoreactive trypsinogen (IRT) and sweat chloride identifies an additional 36% of affected newborns with zero or one detected mutation. The relatives of these affected newborns with less than two detectable mutations have higher posterior (after) 23 mutation-negative test risks of carrying undetected mutations. These calculations emphasize how knowledge of the mutations in the related affected patient substantially improves upon the quality of after-test advice to patients. Furthermore, negative tests of the partner without a family history and/or more extensive cystic fibrosis transmembrane conductance regulator (CFTR) gene testing also increases the likelihood that a negative report is truly negative. When a newborn patient with zero or one detected CFTR mutation has an inconclusive sweat test result, the sweat test should be repeated before ordering additional often unnecessary CFTR gene sequencing. Given the same composite mutation panel test accuracy, a higher proportion of reported test results would be correct during parental screening than when testing at-risk fetuses or symptomatic newborns. Prenatal and newborn screening would be enhanced substantially by medical professionals offering copies of all positive parental and newborn test reports to the parents to share with their relatives. These principles are likely to be applicable to other genetic diseases as the most common mutation frequencies are reported.
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Affiliation(s)
- Roger V Lebo
- Department of Pathology, Akron Children's Hospital, Akron, OH 44308-1062, USA.
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Comeau AM, Accurso FJ, White TB, Campbell PW, Hoffman G, Parad RB, Wilfond BS, Rosenfeld M, Sontag MK, Massie J, Farrell PM, O'Sullivan BP. Guidelines for implementation of cystic fibrosis newborn screening programs: Cystic Fibrosis Foundation workshop report. Pediatrics 2007; 119:e495-518. [PMID: 17272609 DOI: 10.1542/peds.2006-1993] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Newborn screening for cystic fibrosis offers the opportunity for early intervention and improved outcomes. This summary, resulting from a workshop sponsored by the Cystic Fibrosis Foundation to facilitate implementation of widespread high quality cystic fibrosis newborn screening, outlines the steps necessary for success based on the experience of existing programs. Planning should begin with a workgroup composed of those who will be responsible for the success of the local program, typically including the state newborn screening program director and cystic fibrosis care center directors. The workgroup must develop a screening algorithm based on program resources and goals including mechanisms available for sample collection, regional demographics, the spectrum of cystic fibrosis disease to be detected, and acceptable failure rates of the screen. The workgroup must also ensure that all necessary guidelines and resources for screening, diagnosis, and care be in place prior to cystic fibrosis newborn screening implementation. These include educational materials for parents and primary care providers; systems for screening and for providing diagnostic testing and counseling for screen-positive infants and their families; and protocols for care of this unique population. This summary explores the benefits and risks of various screening algorithms, including complex situations that can occur involving unclear diagnostic results, and provides guidelines and sample materials for state newborn screening programs to develop and implement high quality screening for cystic fibrosis.
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Affiliation(s)
- Anne Marie Comeau
- New England Newborn Screening Program and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Parad RB, Comeau AM, Dorkin HL, Dovey M, Gerstle R, Martin T, O'Sullivan BP. Sweat testing infants detected by cystic fibrosis newborn screening. J Pediatr 2005; 147:S69-72. [PMID: 16202787 DOI: 10.1016/j.jpeds.2005.08.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Describe and define limitations of early pilocarpine iontophoresis (sweat testing) for cystic fibrosis (CF) newborn screening (NBS). STUDY DESIGN Population-based results from follow-up of CF NBS-positive newborns. RESULTS Insufficient quantity of sweat is more likely if the sweat test is done too early, but testing is generally successful after 2 weeks of age. Sweat chloride levels drop over the first weeks of life. CF carriers have higher sweat chloride concentrations than non-carriers. CONCLUSIONS Sweat testing can be performed effectively after 2 weeks of age for CF NBS-positive newborns. Earlier testing has a higher risk of insufficient sweat for completing testing.
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Affiliation(s)
- Richard B Parad
- New England Newborn Screening Program of University of Massachusetts Medical School, MA 02130, USA.
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Comeau AM, Parad R, Gerstle R, O'Sullivan BP, Dorkin HL, Dovey M, Haver K, Martin T, Eaton RB. Communications systems and their models: Massachusetts parent compliance with recommended specialty care after positive cystic fibrosis newborn screening result. J Pediatr 2005; 147:S98-100. [PMID: 16202793 DOI: 10.1016/j.jpeds.2005.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate compliance with recommendations for sweat testing/specialty evaluation and genetic counseling after a positive cystic fibrosis newborn screening (CF NBS) result. STUDY DESIGN All infants with positive CF NBS results require a diagnostic sweat test at a CF center. Results that were "screen positive and diagnosis negative" prompted family genetic counseling. Parent compliance with follow-up protocol recommendations was retrospectively analyzed relative to the communications model in place at a particular CF Center. RESULTS At each of the 5 MA CF centers, 95% of the CF NBS-positive infants completed recommended sweat testing. In contrast, there was wide disparity in compliance (32%-90%) with completion of genetic counseling between CF centers. CONCLUSION CF centers that escorted parents through the 2 recommended follow-up steps in 1 day had higher compliance with the second step (genetic counseling) than centers that required a return visit for genetic counseling.
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Affiliation(s)
- Anne Marie Comeau
- New England Newborn Screening Program of the University of Massachusetts Medical School, MA 02130, USA.
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Parad RB, Comeau AM. Diagnostic dilemmas resulting from the immunoreactive trypsinogen/DNA cystic fibrosis newborn screening algorithm. J Pediatr 2005; 147:S78-82. [PMID: 16202789 DOI: 10.1016/j.jpeds.2005.08.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To quantitate the proportion of infants identified through cystic fibrosis (CF) newborn screening (NBS) by an immunoreactive trypsinogen (IRT)/DNA screening algorithm who have an unclear diagnosis as defined by the findings of an elevated IRT level and either 1) 2 CF gene (CFTR) mutations detected and sweat chloride level <60 mEq/L; or 2) 0 or 1 CFTR mutations and a "borderline" sweat chloride level >or=30 and <60 mEq/L. STUDY DESIGN Using the 4-year cohort of CF-affected infants recently described by the Massachusetts CF NBS program, we identified and described the number of infants with the diagnostic characteristics (diagnostic dilemmas) aforementioned. RESULTS Of infants with positive results on CF NBS who had 1 CFTR mutation detected and a borderline sweat chloride concentration, nearly 20% displayed a second CFTR mutation on further evaluation. Of all infants with positive CF NBS results considered affected with CF, 11% had a diagnosis that fell into 1 of the diagnostic dilemma categories aforementioned. CONCLUSIONS Four problematic diagnostic categories generated by CF NBS are defined. In the absence of data on the natural history of such infants, careful follow-up is recommended for infants in whom a definitive diagnosis is elusive.
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Affiliation(s)
- Richard B Parad
- New England Newborn Screening Program, University of Massachusetts Medical School, Boston, Massachusetts 02130, USA.
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Abstract
PURPOSE OF REVIEW Cystic fibrosis (CF) is the most common lethal genetic disorder in the United States to be identified in childhood. In November 2003 the US Cystic Fibrosis Foundation and the Centers for Disease Control and Prevention convened an expert panel to review the indications for CF newborn screening. In this review we discuss the information during the year leading up to this meeting as well as publications since the meeting. RECENT FINDINGS During the past several years an increasing number of CF patients have been diagnosed with newborn screening. These patients have demonstrated several benefits to screening while also uncovering new challenges. Health benefits have included improved nutrition persisting for many years and the avoidance of nutritional complications. Early identification has also meant that these often clinically healthy infants are being followed in CF centers for care. This has added to the need for avoiding infection risks to which these patients might not have otherwise been exposed. Psychosocial benefits include the avoidance of stress due to delayed diagnosis as well as assistance with family planning. Psychosocial challenges include carrier identification and detection of patients with mild disease or without a clear diagnosis. SUMMARY Although no study has definitively shown reduced lung disease or prolonged survival in CF patients detected by newborn screening, the general consensus is that improved nutrition and cognitive potential, in addition to the reduced costs for hospitalization and intensive therapies, support the benefits of screening.
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Affiliation(s)
- Jeffrey S Wagener
- University of Colorado Medical School, Department of Pediatrics, Denver, Colorado, USA.
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