Sunday, September 10, 2006

musings on a sunday

i have a relatively new housemate, since August, really. he's quite nice, quiet, respectful. it's been sort of fun to live with someone after having been on my own for awhile.
well, he went to his brother's wedding this weekend, leaving me with the apartment all to myself, which was sort of nice. i spent the weekend catching up on things that had been piling up during my picu month...bills, laundry, journals, etc.
there was an article in the most recent Pediatrics (Pediatrics 2006;118(3):888-895) about screening for cystic fibrosis with the newborn screen (NBS). they looked at a cohort of children in northwestern Italy diagnosed by NBS between 1997 and 2004, looking to see if there was a difference between the NBS children and the historical controls in the time to infection with Pseudomonas aeruginosa, a bacteria that is associated with a decline in pulmonary function and an increase in morbidity and mortality.
interestingly, they found a shorter mean time to P. aeruginosa infection in the children diagnosed by NBS (183 days for NBS children vs 448 days for historical controls), suggesting that newborns are more readily infected with nosocomial bacteria than older children diagnosed at a later point based on clinical symptoms. this would sort of fit with our understanding of the newborn's evolving immune system.
what this study brings up is that the NBS is not an entirely benign intervention. one could assume that earlier diagnosis and access to treatments and resources would be a positive thing for kids with CF. theoretically, it is. however, we as practitioners need to be vigilant about infection control, with the recognition that our adherence to CF precautions is profoundly important in protecting these vulnerable infants. in our clinic, we see a mixed population of pulmonary pathology, including asthma, CF, PCD, complicated pneumonias, etc. we try to segregate the CF patients to the CF clinic days, but this is not always possible. in addition, the allergy/immunology clinic is run out of the same clinic hallway, increasing the chance for more nosocomial infections. makes me want to carry around lots of alcohol swabs.
coincidentally (or perhaps not), the next article (Pediatrics 2006;118(3):896-905) in the journal was about the cost-effectiveness of various methods of CF NBS in the netherlands, where they use several different methods to confirm the diagnosis. cost-effectiveness studies sort of creep me out a bit. i guess that's the clinician in me. how can you boil a child down to "life years gained" and "willingness to pay values per life year gained"? and whose willingness to pay are we talking about?
another topic this article addressed was parents who chose to terminate the pregnancy if they knew the fetus was affected. in the abstract, i can understand this. however, having met so many kids with CF who lead lives full of happiness and normal kid experiences, albeit punctuated by more frequent visits to their doctor, i struggle with this on a personal level. it is akin to the debate regarding terminations for trisomy 21 fetuses in a way.
i don't pretend to have any answers. just food for thought.


Flea said...

I recall a study demonstrating that even a priori a dx of CF did not affect a parent's decision regarding keeping a pregnancy.

Good analysis of NBS. Ever since the idea was proposed we've been kicking the crap out of it. It's probably time to give it up.



Anonymous said...

However, despite the findings on pa infection, children that are diagnosed earlier have better long-term outcomes in terms of lung function.

Flea said...

Tag! You're it!

Fat Doctor said...

I cannot believe you knew the words to I'm Lovely off the top of your head. Girl, you got some Broadway in you, that's for sure!