Neonatal Screening For Cystic Fibrosis Research Articles

A clinical case of primary ciliary dyskinesia in a child under one year old with a pathogenic genetic variant of the DNAH5 gene described for the first time

Relevance: primary ciliary dyskinesia (PCD) is a rare hereditary autosomal recessive disease from the group of ciliopathies, which is based on a defect in the ultrastructure of the cilia of the epithelium of the respiratory tract and similar structures, leading to a violation of their motor function. It is characterized by the defeat of all parts of the respiratory tract with the formation of a chronic inflammatory process and bronchiectasis. About half of patients with PCD have a complete or incomplete reverse arrangement of internal organs with various variants of heterotaxy (situs inversus). Primary ciliary dyskinesia should be differentiated from cystic fibrosis, primary immunodeficiency conditions, congenital anomalies of the structure of the bronchial tree, bronchiectasis of other origin, bronchial asthma, congenital anomalies of the cardiovascular system. Objective: describe the clinical case of a PCD patient with the first-described pathogenic variant of the nucleotide sequence (chr5:13700862CCATAGA>C) of the DNAH5 gene to familiarize doctors with the clinical features of the disease and modern diagnostic capabilities. Materials and methods: the data from the patient’s medical history, transmission electron microscopy to detect anomalies in the structure of cilia in the biopsy of the nasal mucosa and the results of molecular genetic diagnostics were used. Results. The patient was admitted for 8 months for examination and treatment in June 2022. A child from the 1st pregnancy, the first birth at 43 weeks. From anamnesis: suffered intrauterine pneumonia, otitis media without hearing loss, obstructive bronchitis, episodes of apnea. Neonatal screening for cystic fibrosis is negative. According to the PICADOR scale, 12 points were obtained. On high-speed video microscopy of cilia, there is a violation of the movements of the cilia. On computed tomography of the chest organs, the reverse location of the internal organs was noted, there were no pathological changes in the lungs. The total absence of external and internal dynein handles on transmission electron microscopy was revealed. Exome sequencing revealed the previously described variant of the nucleotide sequence in exon 68 of the DNAH5 gene (chr5:13735348G> A) in a heterozygous state. Also, a previously undescribed variant of the nucleotide sequence (chr5:13700862CCATAGA> C) in a heterozygous state was detected in exon 78 of the DNAH5 gene. Conclusion: modern possibilities of PCD diagnostics are demonstrated by the example of clinical observation. It is noted that patients with suspected PCD need a comprehensive examination. A pathogenic variant of the nucleotide sequence (chr5:13700862CCATAGA>C) of the DNAH5 gene in a heterozygous state has been described for the first time, leading to the deletion of two amino acids without shifting the reading frame (c.13604_13609del p. (Val4535_Tyr4536del); NM_001369.3), which will help for the diagnosis of PCD in the future.

Neonatal Screening for Cystic Fibrosis in Hungary-First-Year Experiences.

The aim of this study is to evaluate the strategy of the cystic fibrosis newborn screening (CFNBS) programme in Hungary based on the results of the first year of screening. A combined immunoreactive trypsinogen (IRT) and pancreatitis-associated protein (PAP) CFNBS protocol (IRT/IRT×PAP/IRT) was applied with an IRT-dependent safety net (SN). Out of 88,400 newborns, 256 were tested screen-positive. Fourteen cystic fibrosis (CF) and two cystic fibrosis-positive inconclusive diagnosis (CFSPID) cases were confirmed from the screen-positive cases, and two false-negative cases were diagnosed later. Based on the obtained results, a sensitivity of 88% and a positive predictive value (PPV) of 5.9% were calculated. Following the recognition of false-negative cases, the calculation method of the age-dependent cut-off was changed. In purely biochemical CFNBS protocols, a small protocol change, even after a short period, can have a significant positive impact on the performance. CFNBS should be monitored continuously in order to fine-tune the screening strategy and define the best local practices.

Comparison between Gibson-Cooke and Macroduct Methods in the Cystic Fibrosis Neonatal Screening Program and in Subjects Who Are Cystic Fibrosis Screen-Positive with an Inconclusive Diagnosis.

The sweat test (ST) is the current diagnostic gold standard for cystic fibrosis (CF). Many CF centres have switched from the Gibson-Cooke method to the Macroduct system-based method. We used these methods simultaneously to compare CF screening outcomes. STs using both methods were performed simultaneously between March and December 2022 at CF Centre in Florence. We included newborns who underwent newborn bloodspot screening (NBS), newborns undergoing transfusion immediately after birth, and children with CF screen-positive, inconclusive diagnosis (CFSPID). We assessed 72 subjects (median age 4.4 months; range 0-76.7): 30 (41.7%) NBS-positive, 18 (25.0%) newborns who underwent transfusion, and 24 (33.3%) children with CFSPID. No significant differences were found between valid sample numbers, by patient ages and groups (p = 0.10) and between chloride concentrations (p = 0.13), except for sweat chloride (SC) measured by the Gibson-Cooke and Macroduct methods in CFSPID group (29.0, IQR: 20.0-48.0 and 22.5, IQR: 15.5-30.8, respectively; p = 0.01). The Macroduct and Gibson-Cooke methods showed substantial agreement with the SC values, except for CFSPID, whose result may depend on the method of sweat collection. In case of invalid values with Macroduct, the test should be repeated with Gibson-Cooke method.

P011 Late diagnosis of cystic fibrosis in adulthood in Republic of North Macedonia

Background: In the era of introduced neonatal screening for cystic fibrosis (CF) in many countries, there are still adults who are late diagnosed for cystic fibrosis. Diagnosis of CF is difficult because of the multisystem nature of the disease and it might be misdiagnosed with asthma, bronchiectasis, pancreatitis, cirrhosis, male infertility.

Atypical form of cystic fibrosis in early childhood

Introduction: Cystic fibrosis (CF) is an autosomal recessive genetic disorder, more prevalent in the Caucasian population. The disease is the result of mutations in a gene that codifies a chloride channel called CFTR (cystic fibrosis transmembrane conductance regulator) at affects most critically the lungs, pancreas, sweat glands and wolffian ducts. The variety of mutations in the CFTR gene is in some way responsible for the clinical variations by having and presentation in its atypical forms. Other factors, such as environmental factors and other genetic modifiers, affect the clinical variability of the disease. Aim: The purpose of the case presentation is to show that CF is also presented with unusual signs and symptoms of the disease, causing it to be diagnosed late in time. Case report: An 8 years old child A.D. admitted to the University Hospital Center of Tirana with a history of hypertransaminasemia, hypergammaglobulinemia and hepatomegaly which were found after a routine check. From the laboratory tests which were normal, causes such as: HIV, Viral Hepatitis, CMV infection, Toxoplasmosis and Rubeola are excluded as causes of increased transaminases and hepatomegaly. Antibodies for autoimmunity and liver-specific antibodies were normal, so autoimmune pathologies were excluded as their cause. Based on the history, the girl had repeated history of pulmonary infections, defecation with a heavy and greasy smell, poor weight gain, mother with a history of two spontaneous abortions, so the cystic fibrosis was suspected. Also, changes with an inflammatory aspect were found in chest radiography. Two sweat tests were performed, which were positive within a period of two weeks. The positive fecal elastase test confirmed pancreatic insufficiency. The child was started therapy with vitamine ADEK and ursodeoxycholic acid and an improvement was observed in the laboratory values ​​of the examinations. Conclusion: Continue neonatal screening for cystic fibrosis. Since we have cases with atypical clinical presentation that are diagnosed late in time when we have cases with hepatic manifestations and the child has a history of repeated respiratory infections, steatorrhea, poor weight gain according to age, a differential diagnosis of hepatic pathologies should be made with Cystic Fibrosis. Since hepatic involvement can be the first manifestation that leads to the diagnosis of cystic fibrosis in its atypical forms.

Update on cystic fibrosis : From neonatal screening to causal treatment

Cystic fibrosis (CF) is a multiorgan disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Approximately 90% of the morbidity and mortality are caused by pulmonary involvement. The mean life expectancy of patients with CF in 2020 was more than 52 years in Germany. The introduction of neonatal screening for CF and the development of a causally acting CFTR modulator treatment have clearly improved the prognosis of these patients. As an introduction, this article describes important aspects of CF in this context in order to go into details of the CF neonatal screening which was introduced in Germany in 2016.

Neonatal cystic fibrosis screening: Analysis and differences in immunoreactive trypsin levels in newborns with a positive screen

IntroductionNeonatal cystic fibrosis (CF) screening has enabled the disease to be diagnosed early, and is a determining factor in the increase in survival of these patients. Its main disadvantage is its low specificity and elevated number of false positives. The aim of this study is to analyse the differences in immunoreactive trypsin (IRT) between the different groups of newborns (NB) with a positive neonatal screen depending on whether they were healthy, healthy carriers, affected by CF, or CFSPID (Cystic Fibrosis Screen Positive, Inconclusive Diagnosis). MaterialRetrospective analytical study of the concentrations of IRT in NB with a positive neonatal screen for CF born in a tertiary hospital during an 8-year period. ResultsA total of 790 NB with a positive neonatal screen for CF were analysed. Of these 86.3% were term, 53% girls, and 11.8% were admitted. The mean IRT value was 79.16 ng/mL (range 60–367). Significantly higher concentrations of IRT were found in those affected by CF compared to the other groups (P < .001). There were higher levels in large prematures (P = .007) and admitted patients (P = .002). There were no differences as regards gender or season. There was a direct correlation of 64% (P = .001) between IRT and sweat test in those affected by CF and CFSPID. A cut-off value of IRT for the diagnosis of CF was calculated from the ROC curve (76.2 ng/mL (S = 95.7%, Sp = 64.5%). ConclusionsNB with CF have significantly higher levels of IRT than healthy ones, or carriers and CFSPID. Prematurity and hospital admission may also have an influence. A higher IRT value is associated with a higher level in the sweat test.

Newborn screening for cystic fibrosis in France

Neonatal screening for cystic fibrosis has optimised the prognosis for patients allowing very early multidisciplinary care. Over the past 20 years, screening programmes have undergone major international expansion. The performances of the French neonatal cystic fibrosis screening programme, established in 2002, has met European guideline standards, with positive predictive value of 0.31 (against a minimum of 0.30) and sensitivity value of 0.95 (against a minimum of 0.95). It is also important to highlight the very high percentage of sweat tests performed (95.5%), of mutations identified (96.6%), the 9:1 ratio of cystic fibrosis cases to cases of inconclusive diagnosis achieved and the effectiveness of the strategy implemented for the detection of false negative cases. A new organisation for cystic fibrosis neonatal screening has now been established in France. It is vital that effectiveness is maintained throughout the process, from newborn maternity care to diagnosis in cystic fibrosis care centres, and that further knowledge is gained through exhaustive data collection and validation.

МУКОВИСЦИДОЗ: ЭТИОЛОГИЯ, ПАТОГЕНЕЗ, КЛИНИКА, РЕЗУЛЬТАТЫ НЕОНАТАЛЬНОГО СКРИНИНГА И ГЕНЕТИЧЕСКИЕ АСПЕКТЫ В РЕСПУБЛИКЕ СЕВЕРНАЯ ОСЕТИЯ – АЛАНИЯ

Cystic fibrosis (CF) is a multisystem disease that affects the respiratory tract, gastrointestinal tract, liver, pancreas, salivary, sweat glands, reproductive system, caused by pathological variants of the CFTR gene located in the long arm of chromosome 7. Considering the fact that CF is the most common hereditary disease, transmitted in an autosomal recessive manner, threatening death and/or disability in case of late diagnosis, the study of population characteristics in different regions is important not only from an epidemiological, but also from a socio-economic point of view. High incidence of CF, the ability to identify the carrier of pathogenic CFTR gene variant, prenatal and preclinical diagnosis, adequate treatment and medical and social adaptation determine the need for organizing mass screening of newborns for this disease. Objective of this research is to evaluate the efficiency of neonatal screening for CF in RNO – Alania, to detect the frequency of its occurrence in the region, and to determine the molecular genetics features of CF in the population. A retrospective analysis of medical records of CF patients diagnosed before neonatal screening was carried out, as well as an analysis of the results of mass newborns screening for CF during 13 years from January 2007 to December 2019. Based on the analysis performed, it was found that the CF frequency in North Ossetia-Alania was 1:16369 live births, which is significantly lower than the average for Russia (1:9500).

Analysis of national coverage of neonatal cystic fibrosis screening in Brazil from 2008 to 2017

Introduction The Brazilian neonatal screening program established in 2001 included the investigation of cystic fibrosis (CF) in the phase III of the program. For this purpose, the immunoreactive trypsin (IRT) measurement was added to the newborn screening test. The purpose of National Neonatal Screening Program is to reach 100% of live births in Brazil. The aim of this study was to analyze the coverage of neonatal Screening for Cystic Fibrosis (CF) in Brazil from 2008 to 2017. Materials and methods This is an ecological study design based on data collected from the Brazilian Outpatient Information System regarding the detection of IRT as a component of the heel stick test from 2008 to 2017. Moreover, we gathered data from the Brazilian Live Birth Information System referring to live births from 2008 to 2017. We calculated the coverage of IRT measurement for every 100 live births, using the number of IRT measurement procedures as the numerator and the number of live births stratified by federative units (states), as well as by the Brazilian regions as the denominator. These regions correspond to the divisions of the national territory based on criteria such as natural, social, cultural and economic aspects. Results From 2008 to 2017, the regions presented the following coverage medians: South (84.1%), Southeast (71.4%), Midwest (47.3%) Northeast (12.3%) and North (10.9%). In the analysis of federative units, in the years 2013 to 2017, Paraná and Distrito Federal presented the highest median of coverage (100%), while the states with the lowest median were Rio Grande do Norte (12.1%), Amazonas (16.8%) and Paraíba (27.5%). Highest coverage was found in the South region, where are located most of the states with high socioeconomic development and high supply of health services, while the lowest coverage was found in the North region, where are located manly the states with low socioeconomic development and low supply of health services. According to data from the Brazilian Ministry of Health, the universalization of neonatal screening for cystic fibrosis occurred in 2013, however, at the end of this year, most states in the North and Northeast regions had not registered IRT measurements in the Outpatient Information System. Conclusion Although the coverage of neonatal screening for CF has improved nationwide over the years of the study, the disparity in the coverage of IRT measurements at the interregional and interstate levels is notable. Systematic implementation of neonatal screening for cystic fibrosis with equity and access to the entire population is suggested, leading to a greater number of children benefiting from treatment and a better quality of life.

P012 Two-year neonatal screening for cystic fibrosis in Republic of North Macedonia

P012 Two-year neonatal screening for cystic fibrosis in Republic of North Macedonia

Clinical and Genotypical Features of False-Negative Patients in 26 Years of Cystic Fibrosis Neonatal Screening in Tuscany, Italy.

Cystic fibrosis (CF) is a life-threatening and common genetic disorder. Cystic fibrosis newborn screening (CF NBS) has been implemented in many countries over the last 30 years, becoming a widely accepted public health strategy in economically developed countries. False-negative (FN) cases can occur after CF NBS, with the number depending on the method. We evaluated the delayed diagnosis of CF, identifying the patients who had false-negative CF NBS results over 26 years (1992–2018) in Tuscany, Italy. The introduction of DNA analysis to the newborn screening protocol improved the sensitivity of the test and reduced the FNs. Our experience showed that, overall, at least 8.7% of cases of CF received FNs (18 cases) and were diagnosed later, with an average age of 6.6 years (range: 4 months to 22 years). Respiratory symptoms and salt-loss syndrome (metabolic hypochloremic alkalosis) are suggestive symptoms of CF and were commons events in FN patients. In Tuscany, a region with a high CFTR allelic heterogeneity, the salt-loss syndrome was a common event in FNs. Therefore, we provided evidence to support the claim that the FN patients had CFTR mutations rarer compared with the true-positive cases. We underline the importance of vigilance toward clinical manifestations suggestive of CF on the part of the primary care providers and hospital physicians in a region with an efficient newborn screening program.

Newborn screening alone insufficient to improve pulmonary outcomes for cystic fibrosis

BackgroundThe Wisconsin Cystic Fibrosis Neonatal Screening Project was a randomized clinical trial (RCT) revealing that children receiving an early diagnosis of CF via newborn screening (NBS) had improved nutritional outcomes but similar lung disease severity compared to those who presented clinically. Because the evaluations of these subjects by protocol ended in 2012, our objective was to assess long-term pulmonary and mortality outcomes. MethodsRetrospective analysis of the RCT cohort utilized longitudinal outcome measures obtained from the Cystic Fibrosis Foundation Patient Registry (CFFPR). Data included screening assignment, clinical characteristics, percent predicted forced expiratory volume in 1 s (ppFEV1) and mortality. A random intercept model was used to compare the ppFEV1 decline of subjects between the two groups up to age 26 years. Mortality was analyzed using the Kaplan-Meier method. ResultsOf the 145 subjects who consented to the original study, 104 subjects met inclusion criteria and had adequate data in the CFFPR. Of 57 subjects in the screened group and 47 in the control group, the rates of ppFEV1 decline were 1.76%/year (95% CI 1.62 to 1.91%) and 1.43%/year (95% CI 1.26 to 1.60%), respectively (p<0.0002). Pseudomonas aeruginosa acquired before 2 years was partially responsible. There was no difference in mortality between the two groups. ConclusionsNBS alone does not improve pulmonary outcomes in CF, particularly when other risk factors supervene. In an era prior to strict infection control and current therapies, NBS for CF may be associated with worse pulmonary outcomes.

Pilot study for cystic fibrosis neonatal screening: the Cuban experience.

Background In Cuba, no screening program for cystic fibrosis (CF) has been implemented yet. The ultramicro enzyme-linked immunosorbent assay (UMELISA)® TIR NEONATAL has been developed for the measurement of immunoreactive trypsin (IRT) in dried blood spots on filter paper. The analytical performance of the kit was evaluated in the national network of laboratories. Methods Newborn dried blood samples (DBS) were evaluated in 16 laboratories. An IRT/IRT/DNA protocol was followed using a cut-off value of 50 ng/mL. The mean, median and percentiles of the distribution were calculated and a two-sample t-test with unequal variance was used for statistical analysis. Influence of perinatal factors on IRT levels was analyzed. Results From January to June 2018, 6470 newborns were studied, obtaining a mean IRT value of 12.09 ng/mL (ranging 0-358 ng/mL) and a median of 8.99 ng/mL. Fifty-two samples (0.78%) were above the cut-off level and 16 samples (0.24%) were elevated in the re-screening process. One of them was confirmed positive by molecular biology (phe508del/c.3120 + 1G > A), constituting the first newborn screened and diagnosed early in Cuba. Second DBS samples were collected on average at 14 days and processed in the laboratory at 16 days of birth. Significant differences were observed (p < 0.05) when evaluating the influence of gender, birth weight (BW) and gestational age (GA) on the IRT values. Lower IRT concentrations were found in samples processed after 10 days of collection. Conclusions The performance of UMELISA® TIR NEONATAL in the laboratories has been satisfactory; hence CF newborn screening (NBS) was extended throughout the country from January 2019.

Pancreatitis-Associated Protein in Neonatal Screening for Cystic Fibrosis: Strengths and Weaknesses.

There are currently four countries and one local region in Europe that use PAP in their newborn screening programme. The first country to employ PAP at a national level was the Netherlands, which started using IRT/PAP/DNA/EGA in 2011. Germany followed in 2016 with a slightly different IRT/PAP/DNA strategy. Portugal also started in 2016, but with an IRT/PAP/IRT programme, and in 2017, Austria changed its IRT/IRT protocol to an IRT/PAP/IRT program. In 2018, Catalonia started to use an IRT/PAP/IRT/DNA strategy. The strengths of PAP are the avoidance of carrier detection and a lower detection rate of CFSPID. PAP seems to have advantages in detecting CF in ethnically-diverse populations, as it is a biochemical approach to screening, which looks for pancreatic injury. Compared to an IRT/IRT protocol, an IRT/PAP protocol leads to earlier diagnoses. While PAP can be assessed with the same screening card as the first IRT, the second IRT in an IRT/IRT protocol requires a second heel prick around the 21st day of the patient’s life. However, IRT/PAP has two main weaknesses. First, an IRT/PAP protocol seems to have a lower sensitivity compared to a well-functioning IRT/DNA protocol, and second, IRT/PAP that is performed as a purely biochemical protocol has a very low positive predictive value. However, if the advantages of PAP are to be exploited, a combination of IRT/PAP with genetic screening or a second IRT as a third tier could be an alternative for a sufficiently performing CF-NBS protocol.

The first five-year evaluation of cystic fibrosis neonatal screening program in São Paulo State, Brazil.

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.

P047 Experience after 1 year of neonatal screening for cystic fibrosis in Luxembourg

P047 Experience after 1 year of neonatal screening for cystic fibrosis in Luxembourg

Оптимизация неонатального скрининга муковисцидоза в региональных условиях

Оптимизация неонатального скрининга муковисцидоза в региональных условиях

Results of the Andalusian Cystic Fibrosis Neonatal Screening Program, 5 Years After Implementation

IntroductionCystic fibrosis neonatal screening (CFNS), based on double determination of immunoreactive trypsinogen ([IRT] [IRT1/IRT2]), has been available in Andalusia since May 2011. If screening is positive, a sweat test is performed, and if that is positive or inconclusive, genetic testing is requested. ObjectiveTo analyze CFNS, based on results from the first 4.5 years of the program. Materials and methodsProspective descriptive study of neonates undergoing CFNS. IRT levels, sweat chloride, and mutations were recorded. Statistical analysis was performed using SPSS 12.0. ResultsBetween May 2011 and December 2016, 474,953 neonates underwent CFNS. Of these, 1087 (0.23%) had elevated IRT2. Since CFNS was introduced, 73 cases of cystic fibrosis were diagnosed; 60 were diagnosed by positive CFNS, and 13 were diagnosed by other means. In one case, the patient developed a typical clinical picture of cystic fibrosis, but had not undergone CFNS at the decision of the parents; the remaining 12 had a negative CFNS (false negatives). Of these, one patient was diagnosed before symptoms developed, as his twin brother had a positive CFNS result; another had chloride at the upper limit of normal, and was subsequently diagnosed with genetic testing before symptoms appeared; and 10 patients developed clinical signs and symptoms. Excluding patients with meconium ileus, sensitivity and specificity of the CFNS program were 85.71% and 99.78%, respectively. The incidence of the disease in Andalusia is 1/6506 live births. ConclusionThese results are a basis for reflection on possible areas for improvement of the CFNS algorithm, and thought may be given to the introduction of genetic studies to increase sensitivity and reduce false positives.

P013 Selection of a genetic test for neonatal screening of cystic fibrosis in the mixed population of Luxembourg

P013 Selection of a genetic test for neonatal screening of cystic fibrosis in the mixed population of Luxembourg