The clinical impact of the Covid-19 pandemic first wave on patients with cystic fibrosis in New York
Simonson, Joseph L; Esposito, Christine; Frantzen, Theresa; Henthorne, Katherine; Espinal, Aileen; Romano, Serena; Ramdeo, Ramona; Trentacoste, Jessica; Tsang, Donna; LaVecchia, Geralyn; Abdullah, Robert; Berdella, Maria; Bonitz, Lynn; Condos, Rany; Constantinescu, Andrei; DeCelie-Germana, Joan K; DiMango, Emily; Draine, Myah; Gimeli, Tara; Giusti, Robert; Guzman, Jessenia; Hammouda, Soumia; Keating, Claire; Kier, Catherine; Lennox, Alison T; Liriano, Carmen; Messer, Zachary; Plachta, Amy; Sadeghi, Hossein; Schwind, Elinor; Stables-Carney, Teresa; Walker, Patricia; Wang, Janice
BACKGROUND:People with cystic fibrosis (pwCF) may be at risk of complications from COVID-19 but the impact of COVID-19 on pwCF remains unknown. METHODS:We conducted a multicenter retrospective cohort study to assess the impact of the COVID-19 pandemic first wave on pwCF in the New York metropolitan area (NY) from March 1, 2020 to August 31, 2020. Objectives were to determine (1) the prevalence of COVID-19 by PCR and IgG antibody testing, (2) the clinical characteristics of COVID-19, (3) delay in routine outpatient care, and (4) the effect on anxiety and depression in pwCF. RESULTS:There were 26 COVID-19 cases diagnosed by PCR or antibody testing among the study cohort of 810 pwCF. The prevalence of COVID-19 by PCR (1.6%) and IgG antibody (12.2%) testing was low. 58% of cases were asymptomatic and 82% were managed at home. 8% were hospitalized and 1 person died. 89% of pwCF experienced delay in care. The prevalence of anxiety increased from 43% baseline to 58% during the pandemic (P<0.01). In post-hoc analysis, the proportion of patients with diabetes (38% versus 16%, P<0.01) and pancreatic insufficiency (96% versus 66%, P<0.01) were higher while CFTR modulator use was lower (46% versus 65%, PÂ =Â 0.05) in pwCF who tested positive for COVID-19. CONCLUSIONS:The prevalence of COVID-19 among pwCF in NY during the pandemic first wave was low and most cases were managed at home. CFTR modulators may be protective. PwCF experienced delay in routine care and increased anxiety.
80 New York Cystic Fibrosis Newborn Screening Consortium quality improvement: Focus on parent and pediatrician education and development of a statewide standard of care for CF-related metabolic syndrome infants
Choudhary, S; Giusti, R; Goetz, D; Kaslovsky, R; Berdella, M; Sadeghi, H; DeCelie-Germana, J; Welter, J; Kier, C; Fortner, C; Voter, K; Kay, D; Hammouda, S
Background: The New York State (NYS) Cystic Fibrosis Newborn Screening Consortium (NYSCFNBS) has cooperated in advocating for continued monitoring of outcomes and improvement in CF newborn screening (NBS) through quality improvement (QI) since 2002. The10 CF Foundation-accredited CF centers have a close working relationship with the NYS Department of Health (DOH) Wadsworth Screening Lab. This cooperative approach has resulted in several interventions to improve the screening program in NYS. In 2002, NYS initiated an IRT, 39 CF mutation screening algorithm. On December 1, 2017, infants with 1 CF mutation identified began to undergo full CFTR gene sequencing; those infants with 2 CF mutations are referred to CF centers. Subsequently, the state replaced the 39 mutation panel with a 338 mutation panel, followed by the sequencing step when 1 CF mutation is detected. The new screening algorithm increases infants classified as CF-related metabolic syndrome (CRMS) in the United States, or CF screen positive inconclusive diagnosis (CFSPID) in Europe. CRMS is used to describe these infants with a sweat chloride value < 30 mmol/L and 2 CFTR mutations, or an intermediate sweat chloride value (30-59 mmol/L) and 1 or no CF-causing mutations. Between 10% and 20% of CRMS/CFSPID individuals can develop clinical features suggestive of CF. This project is an extension of a 2-year CFNBS QI project, which was developed due to the COVID-19 pandemic. NYS was the epicenter of the pandemicin the spring of2020. Due to statewide lockdown, all CF centers were closed for 2 months, and sweat testing for infants with an abnormal CFNBS was not available. Parents of CRMS/CFSPID infants were lost to follow-up because of anxiety about returning to the CF center during the pandemic. This QI project aims to educate the parents and primary care physicians (PCP) to increase awareness and monitor these infants over several years and standardizing care across the 10 NYSCFcare centers.
Method(s): Since the initiation of the sequencing algorithm in December 2017, 250 CRMS/CFSPID infants had been diagnosed. Aparental questionnaire was developed to assess their willingness to be contacted by the CF team to return for a CF clinic visit and repeat swe at test. Parentalagreement to permit the CF team to contact the PCP to educate them concerning CRMS/CFSPID was requested. The questionnaire and QI project were shared with the CF Foundation Clinical Research Community Engagement specialist to facilitate parental feedback from the CF community voice team. Monthly Zoom meetings were held with all 10 NYS CF teams to implement the QI effort.
Result(s): Each CF center is in the process of contacting CRMS/CFSPID patients and their pediatricians and assessing their previous evaluation, including genetic counseling, their knowledge of CRMS/ CFSPID, and willingness to follow up at the CF center again. This data is being collected and analyzed currently.
Conclusion(s): Despite CRMS/ CFSPID guidelines published in 2009 , there is controversy regarding management and follow-up of these infants, as well as on the education of busy PCP on this topic. The NYS NBS program offers a unique opportunity to assess infants with CRMS/CFSPID due to the full genetic sequencing available in these infants, and the NYSCFNBS QI data on the follow-up of these infants will help in the understanding and monitoring of this condition.
Pulmonary Manifestations of Renal Disorders in Children
Malaga-Dieguez, Laura; Trachtman, Howard; Giusti, Robert
The causes of kidney disease in pediatric patients are evenly divided between congenital abnormalities of the kidney and urinary tract and acquired disorders. Nearly 10% to 15% of adults in the United States have chronic kidney disease (CKD); there are no comparable data in children. Regardless of patient age, CKD is a systemic problem that affects every organ system, including the lung. We review the tests used to diagnose and evaluate kidney disease and the main clinical syndromes that are likely to be encountered to aid the pulmonology consultant who is asked to evaluate patients with kidney disease.
Airway manifestations of sarcoidosis in adolescents
Obsekov, Vladislav; Chen, Linda; Pirzada, Melodi; Giusti, Robert; Kazachkov, Mikhail
Endobronchial sarcoid lesions have previously been described and visualized upon bronchoscopy in adult patients with pulmonary sarcoid involvement. Endobronchial ultrasound-guided transbronchial fine-needle aspiration (EBUS-TBNA) has come into favor as the preferred method of diagnosis, but it remains a novel technique in pediatric pulmonology. We describe the first two known cases of visualized endobronchial sarcoid lesions in the pediatric population with pathological confirmation of sarcoidosis with endobronchial and EBUS-TBNA biopsies.
Design and implementation of a custom sequencing panel for CF newborn screening in New York State [Meeting Abstract]
Kay, D; Stevens, C; Sicko, R; Berdella, M; Boyer, J; DeCelie-Germana, J; Dozor, A; Fortner, C N; Giusti, R; Goetz, D M; Guida, L; Hughes, E; Kaslovsky, R; Kier, C; Krein, L; Langfelder-Schwind, E; Saavedra-Matiz, C; Sadeghi, H; Seguin, J M; Soultan, Z N; Ting, A; Torkington-Wood, H; Welter, J; Caggana, M
Background: CF newborn screening (NBS) has high false-positive rates, leading to unnecessary referral of unaffected infants, burdening families. In 2017, a three-tier IRT-DNA-SEQ algorithm was implemented by the NYS NBS program. Referring only infants with two variants resulted in an 83.1% reduction in referrals and a nearly 7-fold increase in positive predictive value (3.7% to 25.2%).
Method(s): A new CFTR algorithm was implemented in 2019. A custom ArcherDx VariantPlex panel utilizing multiplex target enrichment and next-generation sequencing (NGS) technology combines second- and third-tier testing onto a single platform. A panel of 338 CFTR variants are reported for all specimens with high IRT (top 5%). Third-tier full gene sequencing and deletion/duplication (del/dup) analysis is only unblinded in infants with one panel variant or ultra-high IRT.
Result(s): The custom assay's second-tier panel includes all CF-causing sequence variants in CFTR2, including 23 recommended for population- based carrier screening, p.R117H with intron 8 polyT, and additional pathogenic/likely pathogenic variants. Third-tier analysis requires no additional laboratory work. Rather, the full CFTR gene coding sequence and other relevant regions are simply unmasked. Third-tier analysis detects variants not catalogued in CFTR2, and algorithms are used to impute large del/dup that are typically not detectable by sequencing. Approximately 18% of alleles in confirmed cases are detected by sequencing, verifying the diverse NYS CFTR mutation spectrum. However, as expected, a 3-fold increase in the ratio of CF screen positive, inconclusive diagnosis/CFTR-related metabolic syndrome to CF cases is detected. Nearly all of these cases had at least one variant of varying clinical consequence or of uncertain significance and are asymptomatic.
Conclusion(s): The new CFTR assay has higher throughput (96-well format) and is customizable, allowing the Program to add/remove variants from the panel bioinformatically, without assay redesign. Results and outcomes thus far are similar using the two sequencing platforms. Comprehensive genetic analysis allows release of infants without two clinically relevant variants as screen negative, with a recommendation for genetic counseling for carriers
Outcomes in infants identified by IRT-DNASEQ newborn screening algorithm in New York State [Meeting Abstract]
Kay, D; Berdella, M; Boyer, J; DeCelie-Germana, J; Dozor, A; Fortner, C N; Giusti, R; Goetz, D M; Guida, L; Kaslovsky, R; Kier, C; Krein, Lea H; Langfelder-Schwind, E; Laterza, Ozarowski A; Maldonado, V; Martin, L; Saavedra-Matiz, C; Sadeghi, H; Seguin, J M; Soultan, Z N; Ting, A; Torkington-Wood, H; Welter, J; Stevens, C; Caggana, M
CF newborn screening (NBS) began in New York state (NYS) using an immunoreactive trypsinogen (IRT)-DNA algorithm in 2002. On 12/1/2017, NYS became the second in the US to implement enhanced NBS including CFTR sequencing (IRT-DNA-SEQ), with a primary goal of minimizing unnecessary referral of unaffected infants. Infants with high IRT (top 5%) were first screened for 39 CFTR variants using the Luminex xTAG CF39v2 panel. Those with one variant or ultra-high IRT (top 0.1%) were sequenced using MiSeqDx CF Clinical Sequencing Assay (Illumina) with confirmation by Sanger and supplemental testing for specific deletions. Infants with two potentially clinically significant variants were referred to accredited specialty care centers for diagnostic testing. The primary care provider and birth hospital were issued reports for all screen-negative infants, with a recommendation of genetic counseling for carriers. During the first year, >100 different reportable CFTR variants were identified, and 127 infants with two variants were referred. Using the previous IRT-DNA algorithm, 445 carriers and 177 infants with no variants would also have been referred, corresponding to an 83% reduction in referrals with the IRT-DNA-SEQ algorithm. Thirty-one infants have been confirmed to have CF. The median age at earliest consult among CF cases was 12 days (range 0-62), with >=93% seen within 30 days of life. Eighty-six infants with two variants and intermediate/low sweat chloride levels were classified as CFSPID/CRMS and are followed; 83/86 carried 1-2 variants of varying clinical consequence or uncertain significance, compared to only 2/31 CF cases. Such variants with low or variable penetrance complicate diagnosis and prompt long-term follow-up to monitor for symptoms related to CFTR dysfunction or "conversion" to CF. Furthermore, the ratio of CFSPID/CRMS to CF cases increased from 0.9:1 to 2.8:1 overall, and differed by center, ranging from 0.8:1 to 15:0. Sequencing increases lab workload, turnaround times and cost, but is balanced by reduction in follow-up by NBS staff and care centers, and an overall reduction in healthcare costs by elimination of diagnostic evaluation for most infants with false-positive screens. Identification of asymptomatic infants with two CFTR variants and intermediate/negative sweat chloride values poses new clinical and practical challenges for care teams and families
Serum perfluoroalkyl substances and lung function in adolescents exposed to the World Trade Center disaster
Gaylord, Abigail; Berger, Kenneth I; Naidu, Mrudula; Attina, Teresa M; Gilbert, Joseph; Koshy, Tony T; Han, Xiaoxia; Marmor, Michael; Shao, Yongzhao; Giusti, Robert; Goldring, Roberta M; Kannan, Kurunthachalam; Trasande, Leonardo
The effects of childhood exposure to perfluoroalkyl substances (PFASs) on lung function remain mostly unknown. Previous research indicates that children living or going to school near the World Trade Center (WTC) disaster were exposed to high levels of PFASs, among other toxic chemicals. To explore the effects of PFAS exposure on lung function, we measured serum PFASs in a cohort of children from the WTC Health Registry and a matched control group. Perfluorooctanesulfonate had the highest median concentrations in both groups (WTCHR = 3.72â€¯ng/mL, Comparison = 2.75â€¯ng/mL), while the lowest median concentrations were seen for perfluoroundecanoic acid (WTCHR = 0.12â€¯ng/mL, Comparison = 0.01â€¯ng/mL). Lung function outcomes were measured by spirometry, plethysmography, and oscillometry. Asthma diagnosis and serum eosinophil count were also recorded. We examined the relationships of each PFAS with lung function parameters and eosinophil count using linear regressions. Odds ratios for asthma were obtained for each PFAS using logistic regression. The effect of total PFASs on these outcomes was also assessed. All regression models were adjusted for sex, race/ethnicity, age, body mass index (BMI) and tobacco smoke exposure. We found that serum PFASs were not statistically associated with the measured lung function parameters, asthma diagnosis, or eosinophil count in this cohort (pâ€¯<â€¯0.05). These findings highlight the need for more longitudinal studies to explore the long-term effects of childhood PFAS exposure on lung function past adolescence and early adulthood.
NEW YORK STATE CYSTIC FIBROSIS NEWBORN SCREENING: A STATEWIDE QUALITY IMPROVEMENT PROJECT TO ASSESS THE IMPACT OF NEXTGEN SEQUENCING [Meeting Abstract]
Chen, L. M.; Goetz, D. M.; Hammouda, S.; Giusti, R.
OUTCOMES IN INFANTS IDENTIFIED BY IRT-DNA-SEQ NEWBORN SCREENING ALGORITHM IN NEW YORK STATE [Meeting Abstract]
Kay, D.; Berdella, M.; Boyer, J.; DeCelie-Germana, J.; Dozor, A.; Fortner, C. N.; Giusti, R.; Goetz, D. M.; Guida, L.; Kaslovsky, R.; Kier, C.; Lea, Krein H.; Langfelder-Schwind, E.; Ozarowski, Laterza A.; Maldonado, V; Martin, L.; Saavedra-Matiz, C.; Sadeghi, H.; Seguin, J. M.; Soultan, Z. N.; Ting, A.; Torkington-Wood, H.; Welter, J.; Stevens, C.; Caggana, M.
Airway and esophageal eosinophils in children with severe uncontrolled asthma
Erkman, Jessica; Vaynblat, Allen; Thomas, Kristen; Segal, Leopoldo N; Levine, Jeremiah; Moy, Libia; Greifer, Melanie; Giusti, Robert; Shah, Rasik; Kazachkov, Mikhail
AIM/OBJECTIVE:Children with severe uncontrolled asthma (SUA) have a high burden of symptoms and increased frequency of asthma exacerbations. Reflux esophagitis and eosinophilic esophagitis are important co-morbid factors for SUA. Both are associated with the presence of eosinophils in esophageal mucosa. We hypothesized that esophageal eosinophils are frequently present and correlate with the presence of airway eosinophils in children with SUA. METHOD/METHODS:We performed a retrospective analysis of a prospective database of children who underwent "triple endoscopy" (sleep laryngoscopy, bronchoscopy with bronchoalveolar lavage [BAL] and endobronchial biopsy [EBB], and esophagogastroduodenoscopy with esophageal biopsy [EsB]) at our Aerodigestive Center for evaluation of SUA. Children with known cystic fibrosis, primary ciliary dyskinesia, and aspiration-related lung disease were excluded. RESULT/RESULTS:Twenty-four children (21 males) ages 2-16 years were studied. Elevated BAL eosinophils were found in 10 (42%) patients, endobronchial eosinophils in 16 (67%); 7 (29%) had endobronchial eosinophils without elevated BAL eosinophils. Esophageal eosinophils were found in 11 (46%) patients. There was a correlation between the amount of eosinophils in BAL and EBB (Râ€‰=â€‰0.43, Pâ€‰=â€‰0.05) airway eosinophils, defined as elevated BAL and/or EBB eosinophils, correlated with esophageal eosinophils (Râ€‰=â€‰0.41, Pâ€‰=â€‰0.047). CONCLUSION/CONCLUSIONS:We concluded that airway and esophageal eosinophils are frequently present in children with SUA.