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Sanz Fernández M, Mora Sitja M, Carrascón González-Pinto L, López Herce Arteta E, Rodríguez Sánchez A. Assessment of the Degree of Clinical Suspicion of 21-Hydroxylase Deficiency Prior to the Newborn Screening Result. Horm Metab Res 2023; 55:528-535. [PMID: 37328149 DOI: 10.1055/a-2111-6571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The aim of the study was to analyze the clinical suspicion and where patients were when they received the positive result of the neonatal screening for CAH 21OHD. The present data derived from a retrospective analysis of a relatively large group of patients with classical CAH 21OHD patients nosed by newborn screening in Madrid, Spain. During the period from 1990 to 2015 of this study 46 children were diagnosed with classical 21OHD [36 with the salt-wasting (SW) form and 10 with simple virilizing (SV)]. In 38 patients, the disease had not been suspected before the neonatal screening result (30 SW and 8 SV). Thirty patients (79%) were at home without suspicion of any disease, as healthy children, 3 patients (8%) were at home pending completion of the study due to clinical suspicion of any disease (ambiguous genitalia, cryptorchidism) and 5 patients (13%) were admitted to the hospital for reasons unrelated to CAH (sepsis, jaundice, hypoglycemia). It is relevant to note that 69.4% of patients (25/36) with SW form were at home with potential risk of adrenal crisis. Six females had been incorrectly labeled as male at birth. The most frequent reason for clinical suspicion was genital ambiguity in women followed by family history of the disease. Neonatal screening provided better results than clinical suspicion. In the majority of patients with 21OHD the diagnosis by screening was anticipated to the clinical suspicion of the disease even in female patients with ambiguous genitalia.
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Affiliation(s)
- María Sanz Fernández
- Department of Pediatrics & Pediatric Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marina Mora Sitja
- Department of Pediatrics & Pediatric Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Estíbaliz López Herce Arteta
- Department of Pediatrics & Pediatric Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Amparo Rodríguez Sánchez
- Department of Pediatrics & Pediatric Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Yoon YA, Woo S, Kim MS, Kim B, Choi YJ. Establishing 17-Hydroxyprogesterone Cutoff Values for Congenital Adrenal Hyperplasia in Preterm, Low Birth Weight, and Sick Newborns. Exp Clin Endocrinol Diabetes 2023; 131:216-221. [PMID: 36854385 DOI: 10.1055/a-2022-8399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Newborn screening for congenital adrenal hyperplasia (CAH) has benefits with a high adoption rate worldwide. It also has problems of high false positives, which can cause stress to the patient's family with economic losses and unnecessary visits of newborns to hospitals. Therefore, we investigated the influence of birth weight (BW), gestational age (GA), and GA with sampling time on 17-hydroxyprogesterone (17-OHP) concentration and attempted to establish the 17-OHP cutoff values in preterm, low birth weight (LBW), and sick newborns. METHODS Newborns (n=1,071) born between October 2020 and January 2022 were screened for CAH. Samples from neonates were collected on filter paper with the heel prick method. 17-OHP concentration was measured by time-resolved immunofluorescence with an AutoDELFIA Neonatal 17-hydroxyprogesteron kit and grouped in relation to BW, GA, and GA with sampling time. RESULTS The median age of newborns at neonatal sample collection was 6 days. 17-OHP concentration showed a statistically significant negative correlation with BW (r=-0.488, p<0.001) and GA (r=-0.560, p<0.001). Full-term and preterm subgroups had a similar decreasing tendency of 17-OHP concentration with increasing sampling time. Application of newly establishing cutoff criteria significantly reduced recall rates to 1.16%, 0.9%, and 1.75% according to each criterion of BW, GA, and GA with sampling time, respectively. CONCLUSIONS This study presents new 17-OHP cutoff values for preterm, LBW, and sick newborns. These data in our laboratory can be used as a reference by other laboratories for establishing new cutoff criteria to help lower the high recall rate and reduce unnecessary follow-up tests.
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Affiliation(s)
- Young Ahn Yoon
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Suhyeon Woo
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Min-Sun Kim
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Bohyun Kim
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Young-Jin Choi
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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Matharu PK, Held PK, Allen DB. Multiple 17-OHP Cutoff Co-Variates Fail to Improve 21-Hydroxylase Deficiency Screening Accuracy. Int J Neonatal Screen 2022; 8:ijns8040057. [PMID: 36412583 PMCID: PMC9680344 DOI: 10.3390/ijns8040057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/18/2022] [Accepted: 10/21/2022] [Indexed: 12/14/2022] Open
Abstract
To improve the positive predictive value (PPV) of newborn screening for 21-hydroxylase deficiency (21OHD), co-variates have been used to modify 17-hydroxyprogesterone (17OHP) cutoffs. The objective of this study is to evaluate whether 17OHP screening cutoffs adjusted for both collection time (CT) and birth weight (BW) improved the sensitivity and PPV of 21OHD screening. Unaffected newborn screening samples were stratified based on BW and CT to establish 17OHP concentration cutoffs at the 95th and 99th percentile. These cutoffs were applied to a cohort of confirmed cases of 21OHD to determine the sensitivity and PPV of the modified screening parameters. 17OHP cutoffs at the 99th percentile, adjusted for BW and CT, had a sensitivity of 96.3% and a specificity of 98.9%, but a relatively low PPV (0.130) for the identification of 21OHD and did not detect all cases. Use of the 95th percentile further increased sensitivity to 98.1% but resulted in a notably lower PPV (0.027). Alternative approaches that do not rely exclusively on 17OHP are needed to improve newborn screening accuracy for 21OHD.
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Affiliation(s)
- Preet K. Matharu
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA
| | - Patrice K. Held
- Oregon State Public Health Laboratory, Oregon Health Authority, Hillsboro, OR 97124, USA
| | - David B. Allen
- Department of Pediatrics, Division of Endocrinology and Diabetes, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
- Correspondence: ; Tel.: +1-608-263-5835
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Held PK, Bialk ER, Lasarev MR, Allen DB. 21-Deoxycortisol is a Key Screening Marker for 21-Hydroxylase Deficiency. J Pediatr 2022; 242:213-219.e1. [PMID: 34780778 DOI: 10.1016/j.jpeds.2021.10.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/11/2021] [Accepted: 10/31/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To assess whether 21-deoxycortisol (21deoxy) can be used to predict 21-hydroxylase deficiency (21OHD) in newborns and to evaluate the influence of gestational age and the timing of collection on 21deoxy concentrations. STUDY DESIGN 17-hydroxyprogesterone (17OHP) and 21deoxy levels were measured in 906 newborn screening specimens (851 unaffected newborns, 55 confirmed cases of 21OHD) to compare their ability to identify babies with 21OHD. In addition, these 2 steroids were assessed in the unaffected cohort to determine the influence of gestational age (ranging from 23 to 42 weeks) and the timing of specimen collection on the measured concentrations. RESULTS The gestational age of the newborn impacted both 17OHP and 21deoxy concentrations, but the degree of influence was more substantial for 17OHP. Timing of collection did not affect 21deoxy concentration. Moreover, 21deoxy was a better predictor of 21OHD status compared with 17OHP, with little overlap in concentrations between the unaffected population and confirmed cases of 21OHD. A streamlined decision tree using solely 21deoxy (cutoff value, 0.85 ng/mL) yielded a 91.7% positive predictive value for 21OHD screening. CONCLUSIONS Our findings demonstrate that 21deoxy is a key disease marker of 21OHD and can be used to improve the accuracy of newborn screening for this disorder.
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Affiliation(s)
- Patrice K Held
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI; Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Eric R Bialk
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Michael R Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - David B Allen
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Tsuji-Hosokawa A, Kashimada K. Thirty-Year Lessons from the Newborn Screening for Congenital Adrenal Hyperplasia (CAH) in Japan. Int J Neonatal Screen 2021; 7:ijns7030036. [PMID: 34209888 PMCID: PMC8293132 DOI: 10.3390/ijns7030036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 01/02/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) is an inherited disorder caused by the absence or severely impaired activity of steroidogenic enzymes involved in cortisol biosynthesis. More than 90% of cases result from 21-hydroxylase deficiency (21OHD). To prevent life-threatening adrenal crisis and to help perform appropriate sex assignments for affected female patients, newborn screening (NBS) programs for the classical form of CAH have been introduced in numerous countries. In Japan, the NBS for CAH was introduced in 1989, following the screenings for phenylketonuria and congenital hypothyroidism. In this review, we aim to summarize the experience of the past 30 years of the NBS for CAH in Japan, composed of four parts, 1: screening system in Japan, 2: the clinical outcomes for the patients with CAH, 3: various factors that would impact the NBS system, including timeline, false positive, and LC-MS/MS, 4: Database composition and improvement of the screening program.
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Affiliation(s)
- Atsumi Tsuji-Hosokawa
- Department of Systems BioMedicine, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan;
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
- Correspondence:
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Held PK, Bird IM, Heather NL. Newborn Screening for Congenital Adrenal Hyperplasia: Review of Factors Affecting Screening Accuracy. Int J Neonatal Screen 2020; 6:67. [PMID: 33117906 PMCID: PMC7569755 DOI: 10.3390/ijns6030067] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/17/2020] [Indexed: 12/28/2022] Open
Abstract
Newborn screening for 21-hydroxylase deficiency (21OHD), the most common form of congenital adrenal hyperplasia, has been performed routinely in the United States and other countries for over 20 years. Screening provides the opportunity for early detection and treatment of patients with 21OHD, preventing salt-wasting crisis during the first weeks of life. However, current first-tier screening methodologies lack specificity, leading to a large number of false positive cases, and adequate sensitivity to detect all cases of classic 21OHD that would benefit from treatment. This review summarizes the pathology of 21OHD and also the key stages of fetal hypothalamic-pituitary-adrenal axis development and adrenal steroidogenesis that contribute to limitations in screening accuracy. Factors leading to both false positive and false negative results are highlighted, along with specimen collection best practices used by laboratories in the United States and worldwide. This comprehensive review provides context and insight into the limitations of newborn screening for 21OHD for laboratorians, primary care physicians, and endocrinologists.
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Affiliation(s)
- Patrice K. Held
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA
| | - Ian M. Bird
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53715, USA;
| | - Natasha L. Heather
- Newborn Screening, LabPlus, Auckland City Hospital, Auckland 1023, New Zealand;
- Liggins Institute, University of Auckland, Auckland 1010, New Zealand
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Zetterström RH, Karlsson L, Falhammar H, Lajic S, Nordenström A. Update on the Swedish Newborn Screening for Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency. Int J Neonatal Screen 2020; 6:ijns6030071. [PMID: 33239597 PMCID: PMC7570065 DOI: 10.3390/ijns6030071] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 11/16/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) was the fourth disorder added to the national Swedish neonatal screening program in 1986, and approximately 115,000 newborns are screened annually. Dried blood spot (DBS) screening with measurement of 17-hydroxyprogesterone (17OHP) is also offered to older children moving to Sweden from countries lacking a national DBS screening program. Here, we report an update on the CAH screening from January 2011 until December 2019. Results: During the study period, 1,030,409 newborns and 34,713 older children were screened. In total, 87 newborns were verified to have CAH, which gives an overall positive predictive value (PPV) of 11% and 21% for term infants. Including the five missed CAH cases identified during this period, this gives an incidence of 1:11,200 of CAH in Sweden. Among the older children, 12 of 14 recalled cases were found to be true positive for CAH. All patients were genotyped as part of the clinical follow-up and 70% of the newborns had salt wasting (SW) CAH and 92% had classic CAH (i.e., SW and simple virilizing (SV) CAH). In the group of 12 older children, none had SW CAH and two had SV CAH. Conclusion: The incidence of classic CAH is relatively high in Sweden. Early genetic confirmation with CYP21A2 genotyping has been a valuable complement to the analysis of 17OHP to predict disease severity, make treatment decisions and for the follow-up and evaluation of the screening program.
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Affiliation(s)
- Rolf H. Zetterström
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital, SE-171 76 Stockholm, Sweden; (R.H.Z.); (L.K.)
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden;
| | - Leif Karlsson
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital, SE-171 76 Stockholm, Sweden; (R.H.Z.); (L.K.)
- Department of Women’s and Children’s Health, Karolinska Institutet, SE-171 76 Stockholm, Sweden;
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden;
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, SE-171 77 Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women’s and Children’s Health, Karolinska Institutet, SE-171 76 Stockholm, Sweden;
- Pediatric Endocrinology Unit, Astrid Lindgren´s Children’s Hospital, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Anna Nordenström
- Centre for Inherited Metabolic Diseases, Karolinska University Hospital, SE-171 76 Stockholm, Sweden; (R.H.Z.); (L.K.)
- Department of Women’s and Children’s Health, Karolinska Institutet, SE-171 76 Stockholm, Sweden;
- Pediatric Endocrinology Unit, Astrid Lindgren´s Children’s Hospital, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Correspondence:
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Lasarev MR, Bialk ER, Allen DB, Held PK. Application of Principal Component Analysis to Newborn Screening for Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2020; 105:5856153. [PMID: 32525982 DOI: 10.1210/clinem/dgaa371] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE Newborn screening laboratories are challenged to develop reporting algorithms that accurately identify babies at increased risk for congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (21OHD). Screening algorithms typically use cutoff values for a key steroid(s) and include considerations for covariates, such as gestational age or birth weight, but false-positive and false-negative results are still too frequent, preventing accurate assessments. Principal component analysis (PCA) is a statistical method that reduces high-dimensional data to a small number of components, capturing patterns of association that may be relevant to the outcome of interest. To our knowledge, PCA has not been evaluated in the newborn screening setting to determine whether it can improve the positive predictive value of 21OHD screening. METHODS PCA was applied to a data set of 920 newborns with measured concentrations of 5 key steroids that are known to be perturbed in patients with 21OHD. A decision tree for the known outcomes (confirmed 21OHD cases and unaffected individuals) was created with 2 principal components as predictors. The effectiveness of the PCA-derived decision tree was compared with the current algorithm. RESULTS PCA improved the positive predictive value of 21OHD screening from 20.0% to 66.7% in a retrospective study comparing the current algorithm to a tree-based algorithm using PCA-derived variables. The streamlined PCA-derived decision tree, comprising only 3 assessment points, greatly simplified the 21OHD reporting algorithm. CONCLUSIONS This first report of PCA applied to newborn screening for 21OHD demonstrates enhanced detection of affected individuals within the unaffected population.
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Affiliation(s)
- Michael R Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Eric R Bialk
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David B Allen
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Patrice K Held
- Wisconsin State Laboratory of Hygiene, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Peng G, Tang Y, Cowan TM, Zhao H, Scharfe C. Timing of Newborn Blood Collection Alters Metabolic Disease Screening Performance. Front Pediatr 2020; 8:623184. [PMID: 33553077 PMCID: PMC7854909 DOI: 10.3389/fped.2020.623184] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/22/2020] [Indexed: 12/02/2022] Open
Abstract
Blood collection for newborn genetic disease screening is preferably performed within 24-48 h after birth. We used population-level newborn screening (NBS) data to study early postnatal metabolic changes and whether timing of blood collection could impact screening performance. Newborns were grouped based on their reported age at blood collection (AaBC) into early (12-23 h), standard (24-48 h), and late (49-168 h) collection groups. Metabolic marker levels were compared between the groups using effect size analysis, which controlled for group size differences and influence from the clinical variables of birth weight and gestational age. Metabolite level differences identified between groups were correlated to NBS data from false-positive cases for inborn metabolic disorders including carnitine transport defect (CTD), isovaleric acidemia (IVA), methylmalonic acidemia (MMA), and phenylketonuria (PKU). Our results showed that 56% of the metabolites had AaBC-related differences, which included metabolites with either decreasing or increasing levels after birth. Compared to the standard group, the early-collection group had elevated marker levels for PKU (phenylalanine, Cohen's d = 0.55), IVA (C5, Cohen's d = 0.24), MMA (C3, Cohen's d = 0.23), and CTD (C0, Cohen's d = 0.23). These findings correlated with higher false-positive rates for PKU (P < 0.05), IVA (P < 0.05), and MMA (P < 0.001), and lower false-positive rate for CTD (P < 0.001) in the early-collection group. Blood collection before 24 h could affect screening performance for some metabolic disorders. We have developed web-based tools integrating AaBC and other variables for interpretive analysis of screening data.
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Affiliation(s)
- Gang Peng
- Department of Genetics, Yale University School of Medicine, New Haven, CT, United States.,Department of Biostatistics, Yale University School of Public Health, New Haven, CT, United States
| | - Yishuo Tang
- Department of Genetics, Yale University School of Medicine, New Haven, CT, United States
| | - Tina M Cowan
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
| | - Hongyu Zhao
- Department of Genetics, Yale University School of Medicine, New Haven, CT, United States.,Department of Biostatistics, Yale University School of Public Health, New Haven, CT, United States
| | - Curt Scharfe
- Department of Genetics, Yale University School of Medicine, New Haven, CT, United States
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Jiang X, Tang F, Feng Y, Li B, Jia X, Tang C, Liu S, Huang Y. The adjustment of 17-hydroxyprogesterone cut-off values for congenital adrenal hyperplasia neonatal screening by GSP according to gestational age and age at sampling. J Pediatr Endocrinol Metab 2019; 32:1253-1258. [PMID: 31603856 DOI: 10.1515/jpem-2019-0140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/12/2019] [Indexed: 11/15/2022]
Abstract
Background Congenital adrenal hyperplasia (CAH) screening is facing great challenges because of a high false-positive rate and a low positive predictive value (PPV). We established and optimized 17-hydroxyprogesterone (17-OHP) cut-off values for CAH neonatal screening using a genetic screening processor (GSP) according to gestational age (GA), birth weight (BW) and age at sampling. Methods The 17-OHP concentrations in dried blood spots were measured by time-resolved immunofluorescence and were grouped in terms of GA, BW and age at sampling for 48,592 newborns. The 99.5th percentile was used to set an initial cut-off value as a reference. Results Significant differences in 17-OHP concentrations were observed among newborns with different GAs and BWs. A significant difference was observed among different sampling age groups. Finally, we defined new multitier cut-off concentrations based on GA and age at sampling. Application of the new cut-off values resulted in a 30% reduction of the positive rate and a 40% increase of the PPV. Conclusions GA, BW and sampling age time influenced the concentrations of 17-OHP. The efficiency of congenital adrenal hyperplasia screening can be substantially improved by adjusting the multitier cut-off value according to GA and age at sampling.
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Affiliation(s)
- Xiang Jiang
- Guangzhou Newborn Screening Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P.R. China
| | - Fang Tang
- Guangzhou Newborn Screening Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P.R. China
| | - Yi Feng
- Guangzhou Newborn Screening Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P.R. China
| | - Bei Li
- Guangzhou Newborn Screening Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P.R. China
| | - Xuefang Jia
- Guangzhou Newborn Screening Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P.R. China
| | - Chengfang Tang
- Guangzhou Newborn Screening Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P.R. China
| | - Sichi Liu
- Guangzhou Newborn Screening Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, P.R. China
| | - Yonglan Huang
- Guangzhou Newborn Screening Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510180, Guangdong Province,P.R. China, Phone/Fax: +86-20-81330406
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Cicalini I, Tumini S, Guidone PI, Pieragostino D, Zucchelli M, Franchi S, Lisi G, Lelli Chiesa P, Stuppia L, De Laurenzi V, Rossi C. Serum Steroid Profiling by Liquid Chromatography-Tandem Mass Spectrometry for the Rapid Confirmation and Early Treatment of Congenital Adrenal Hyperplasia: A Neonatal Case Report. Metabolites 2019; 9:metabo9120284. [PMID: 31766536 PMCID: PMC6950672 DOI: 10.3390/metabo9120284] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) describes a group of autosomal recessive disorders of steroid biosynthesis, in 95% of cases due to 21-hydroxylase deficiency. The resulting hormonal imbalances lead to increased 17-hydroxyprogesterone and androgens levels, at the expense of decreased concentrations of glucocorticoids and, in some cases, of mineralocorticoids. A variety of clinical presentations accompany a range of severities, which are described as different forms of CAH, and are the result of these hormonal imbalances. The incidence of CAH worldwide is approximately 1 in 15,000 live births, and is population-dependent; thus, its inclusion in neonatal screening tests is widely discussed. Diagnosis of CAH is based on the quantification of 17-hydroxyprogesterone, usually by immunoassay, which has low specificity and high false-positive rates, resulting in a relatively high demand for a second-tier confirmation test. We report a case of a newborn recognized as female at birth, but showing ambiguous genitalia and other CAH clinical features, including hypernatremia, in the first days of life. In addition to the classical assays, liquid chromatography–tandem mass spectrometry was used to determine the serum steroid profile, allowing for the accurate and simultaneous quantification of seven steroids in the same analysis. Such an application immediately revealed an alteration in the levels of specific steroids related to CAH, leading to an early intervention by hormone replacement therapy. Subsequently, the diagnosis of classic CAH due to 21-hydroxylase deficiency was further confirmed by molecular testing.
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Affiliation(s)
- Ilaria Cicalini
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66013 Chieti, Italy; (G.L.); (P.L.C.)
| | - Stefano Tumini
- Department of Pediatrics, “G. d’Annunzio” University, 66100 Chieti, Italy;
| | - Paola Irma Guidone
- Department of Pediatrics, “Ospedale della Murgia—Fabio Perinei ”, 70022 Altamura, Italy;
| | - Damiana Pieragostino
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Mirco Zucchelli
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Sara Franchi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Psychological, Healthand Territory Sciences, School of Medicine and Health Sciences, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Gabriele Lisi
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66013 Chieti, Italy; (G.L.); (P.L.C.)
- Department of Pediatric Surgery, Pescara Hospital, 65124 Pescara, Italy
| | - Pierluigi Lelli Chiesa
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66013 Chieti, Italy; (G.L.); (P.L.C.)
- Department of Pediatric Surgery, Pescara Hospital, 65124 Pescara, Italy
| | - Liborio Stuppia
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Psychological, Healthand Territory Sciences, School of Medicine and Health Sciences, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Vincenzo De Laurenzi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Claudia Rossi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (I.C.); (D.P.); (M.Z.); (S.F.); (L.S.); (V.D.L.)
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66013 Chieti, Italy; (G.L.); (P.L.C.)
- Correspondence:
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12
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Wisconsin's Screening Algorithm for the Identification of Newborns with Congenital Adrenal Hyperplasia. Int J Neonatal Screen 2019; 5:33. [PMID: 33072992 PMCID: PMC7510207 DOI: 10.3390/ijns5030033] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/02/2019] [Indexed: 11/29/2022] Open
Abstract
Newborn screening for congenital adrenal hyperplasia (CAH) has one of the highest false positive rates of any of the diseases on the Wisconsin panel. This is largely due to the first-tier immune assay cross-reactivity and physiological changes in the concentration of 17-hydroxyprogesterone during the first few days of life. To improve screening for CAH, Wisconsin developed a second-tier assay to quantify four different steroids (17-hydroxyprogesterone, 21-deoxycortisol, androstenedione, and cortisol) by liquid chromatography-tandem mass spectrometry (LC-MSMS) in dried blood spots. From validation studies which included the testing of confirmed CAH patients, Wisconsin established its own reporting algorithm that incorporates steroid concentrations as well as two different ratios-the birth weight and the collection time-to identify babies at risk for CAH. Using the newly developed method and algorithm, the false positive rate for the CAH screening was reduced by 95%. Patients with both classical forms of CAH, salt-wasting and simple virilizing, were identified. This study replicates and expands upon previous work to develop a second-tier LC-MSMS steroid profiling screening assay for CAH. The validation and prospective study results provide evidence for an extensive reporting algorithm that incorporates multiple steroids, birth weight, and collection times.
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Pode-Shakked N, Blau A, Pode-Shakked B, Tiosano D, Weintrob N, Eyal O, Zung A, Levy-Khademi F, Tenenbaum-Rakover Y, Zangen D, Gillis D, Pinhas-Hamiel O, Loewenthal N, de Vries L, Landau Z, Rachmiel M, Abu-Libdeh A, Eliakim A, Strich D, Koren I, German A, Sack J, Almashanu S. Combined Gestational Age- and Birth Weight-Adjusted Cutoffs for Newborn Screening of Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2019; 104:3172-3180. [PMID: 30865229 DOI: 10.1210/jc.2018-02468] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/07/2019] [Indexed: 02/08/2023]
Abstract
CONTEXT Congenital adrenal hyperplasia (CAH) was among the first genetic disorders included in newborn screening (NBS) programs worldwide, based on 17α-hydroxyprogesterone (17-OHP) levels in dried blood spots. However, the success of NBS for CAH is hampered by high false positive (FP) rates, especially in preterm and low-birthweight infants. OBJECTIVE To establish a set of cutoff values adjusting for both gestational age (GA) and birthweight (BW), with the aim of reducing FP rates. DESIGN This cross-sectional, population-based study summarizes 10 years of experience of the Israeli NBS program for diagnosis of CAH. Multitiered 17-OHP cutoff values were stratified according to both BW and GA. PARTICIPANTS A total of 1,378,132 newborns born between 2008 and 2017 were included in the NBS program. RESULTS Eighty-eight newborns were ultimately diagnosed with CAH; in 84 of these, CAH was detected upon NBS. The combined parameters-adjusted approach significantly reduced the recall FP rate (0.03%) and increased the positive predictive value (PPV) (16.5%). Sensitivity among those referred for immediate attention increased significantly (94%). There were four false negative cases (sensitivity, 95.4%), all ultimately diagnosed as simple-virilizing. Sensitivity and specificity were 95.4% and 99.9%, respectively, and the percentage of true-positive cases from all newborns referred for evaluation following a positive NBS result was 96%. CONCLUSIONS The use of cutoff values adjusted for both GA and BW significantly reduced FP rates (0.03%) and increased overall PPV (16.5%). Based on our 10 years of experience, we recommend the implementation of this two parameter-adjusted approach for NBS of classic CAH in NBS programs worldwide.
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Affiliation(s)
- Naomi Pode-Shakked
- Pediatric Department A, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
- The Dr. Pinchas Borenstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ayala Blau
- The National Newborn Screening Program, Ministry of Health, Tel-Hashomer, Israel
- Nursing Department, School of Health Sciences, Ariel University, Ariel, Israel
| | - Ben Pode-Shakked
- The Dr. Pinchas Borenstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- The Danek Gertner Institute of Human Genetics, Sheba Medical Center, Tel-Hashomer, Israel
| | - Dov Tiosano
- Division of Pediatric Endocrinology, Mayer Children's Hospital, Rambam Medical Center, Haifa, Israel
- The Rappaport Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa, Israel
| | - Naomi Weintrob
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Pediatric Endocrinology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Ori Eyal
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Pediatric Endocrinology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Amnon Zung
- Pediatrics Department, Kaplan Medical Center, Rehovot, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
| | - Floris Levy-Khademi
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
- Division of Pediatric Endocrinology, Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yardena Tenenbaum-Rakover
- The Rappaport Faculty of Medicine, The Technion - Israel Institute of Technology, Haifa, Israel
- Pediatric Endocrine Institute, Ha'Emek Medical Center, Afula, Israel
| | - David Zangen
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - David Gillis
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical School, Jerusalem, Israel
- Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Orit Pinhas-Hamiel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Neta Loewenthal
- Pediatric Endocrinology Diabetes Unit, Soroka Medical Center, Beer Sheva, Israel
- Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Liat de Vries
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Zohar Landau
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Pediatric Endocrine and Diabetes Unit, E. Wolfson Medical Center, Holon, Israel
| | - Mariana Rachmiel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Pediatric Endocrinology Unit, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Abdulsalam Abu-Libdeh
- Pediatric Department, Division of Pediatric Endocrinology, Makassed Islamic Hospital, Jerusalem, Mount of Olives, Israel
| | - Alon Eliakim
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Child Health and Sport Center, Pediatric Department, Meir Medical Center, Kfar Saba, Israel
| | - David Strich
- Clalit Health Services, Jerusalem District, Israel
- Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ilana Koren
- Pediatric Endocrinology Armon Child Center, Clalit Health Services, Haifa, Israel
| | - Alina German
- Department of Pediatrics, Bnai Zion Medical Center, Haifa, Israel
| | - Joseph Sack
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shlomo Almashanu
- The National Newborn Screening Program, Ministry of Health, Tel-Hashomer, Israel
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Kum CD, Lee MJ, Park MS, Sohn YB, Noh OK, Lee JH. Analysis of the Influencing Factors of 17-Hydroxyprogesterone Level and the Correlation between 17-Hydroxyprogesterone Level and the Clinical Parameters Related to Adrenal Cortical Function in Very-Low-Birth-Weight Infants. NEONATAL MEDICINE 2019. [DOI: 10.5385/nm.2019.26.1.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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15
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Güran T, Tezel B, Gürbüz F, Selver Eklioğlu B, Hatipoğlu N, Kara C, Şimşek E, Çizmecioğlu FM, Ozon A, Baş F, Aydın M, Darendeliler F. Neonatal Screening for Congenital Adrenal Hyperplasia in Turkey: A Pilot Study with 38,935 Infants. J Clin Res Pediatr Endocrinol 2019; 11:13-23. [PMID: 30111524 PMCID: PMC6398187 DOI: 10.4274/jcrpe.galenos.2018.2018.0117] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/10/2018] [Indexed: 12/01/2022] Open
Abstract
Objective Congenital adrenal hyperplasia (CAH) is the most common form of primary adrenal insufficiency in children. Neonatal screening for CAH is effective in detecting the salt-wasting (SW) form and in reducing mortality. In this study, our aim was to estimate the incidence of CAH in Turkey and to assess the characteristics and efficacy of the adopted newborn CAH screening strategy. Methods A pilot newborn CAH screening study was carried out under the authority of the Turkish Directorate of Public Health. Newborn babies of ≥32 gestational weeks and ≥1500 gr birth weight from four cities, born between March 27-September 15, 2017 were included in the study. Screening protocol included one sample two-tier testing. In the first step, 17α-hydroxyprogesterone (17-OHP) was measured by fluoroimmunoassay in dried blood spots (DBS) obtained at 3-5 days of life. The cases with positive initial screening were tested by steroid profiling in DBS using a liquid chromatography-tandem mass spectrometry method to measure 17-OHP, 21-deoxycortisol (21-S), cortisol (F), 11-deoxycortisol and androstenedione as a second-tier test. The babies with a steroid ratio (21-S+17-OHP)/F of ≥0.5 were referred to pediatric endocrinology clinics for diagnostic assessment. Results 38,935 infants were tested, 2265 (5.82%) required second-tier testing and 212 (0.54%) were referred for clinical assessment, six of whom were diagnosed with CAH (four males, two females). Four cases were identified as SW 21-hydroxylase deficiency (21-OHD) (two males, two females). One male baby had simple virilizing 21-OHD and one male baby had 11-OHD CAH. The incidence of classical 21-OHD in the screened population was 1:7,787. Conclusion The incidence of CAH due to classical 21-OHD is higher in Turkey compared to previous reports. We, therefore, suggest that CAH be added to the newborn screening panel in Turkey. The use of steroid profiling as a second-tier test was found to improve the efficacy of the screening and reduce the number of false-positives.
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Affiliation(s)
- Tülay Güran
- Marmara University Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, İstanbul, Turkey
| | - Başak Tezel
- Turkish Directorate of Public Health, Ankara, Turkey
| | - Fatih Gürbüz
- Çukurova University Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, Adana, Turkey
| | - Beray Selver Eklioğlu
- Necmettin Erbakan University Meram Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, Konya, Turkey
| | - Nihal Hatipoğlu
- Erciyes University Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, Kayseri, Turkey
| | - Cengiz Kara
- Ondokuz Mayıs University Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, Samsun, Turkey
| | - Enver Şimşek
- Osmangazi University Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, Eskişehir, Turkey
| | - Filiz Mine Çizmecioğlu
- Kocaeli University Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, Kocaeli, Turkey
| | - Alev Ozon
- Hacettepe University Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, Ankara, Turkey
| | - Firdevs Baş
- İstanbul University İstanbul Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, İstanbul, Turkey
| | - Murat Aydın
- Ondokuz Mayıs University Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, Samsun, Turkey
| | - Feyza Darendeliler
- İstanbul University İstanbul Faculty of Medicine, Department of Paediatric Endocrinology and Diabetes, İstanbul, Turkey
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 554] [Impact Index Per Article: 92.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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17
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Cavarzere P, Mauro M, Vincenzi M, Lauriola S, Teofoli F, Gaudino R, Ramaroli DA, Micciolo R, Camilot M, Antoniazzi F. Children with premature pubarche: is an alterated neonatal 17-Ohp screening test a predictive factor? Ital J Pediatr 2018; 44:10. [PMID: 29338783 PMCID: PMC5771218 DOI: 10.1186/s13052-018-0444-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neonatal screening for 21 hydroxylase deficiency is designed to detect classical form of congenital adrenal hyperplasia (CAH). It is still unclear whether newborns who result false positives at neonatal screening might later develop signs of androgen excess. The aim of this study is to verify whether a slightly elevated 17-OHP at newborn screening is a predictive factor for premature pubarche. METHODS We evaluated all infants born between 2001 and 2014 with premature pubarche. In case of increased bone age, they were submitted to functional tests to find out the cause of their symptoms. Their 17-OHP values at newborn screening for CAH were reconsidered. RESULTS We identified 330 patients (269 females, 61 males) with premature pubarche. All these children had a normal 17-OHP at newborn screening with the exception of a child, born preterm and not affected by CAH. CONCLUSIONS An elevated 17-OHP at newborn screening is not a predictive factor for premature pubarche. A likely cause of increased 17-OHP level at screening is an immaturity of adrenal gland or a neonatal stress. Therefore a strict follow up of these neonates during childhood is not necessary.
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Affiliation(s)
- Paolo Cavarzere
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy.
| | - Margherita Mauro
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy
| | - Monica Vincenzi
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy
| | - Silvana Lauriola
- Department of Pediatrics, Neonatal Intensive Care Unit, University Hospital of Verona, Verona, Italy
| | - Francesca Teofoli
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy
| | - Rossella Gaudino
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy
| | - Diego Alberto Ramaroli
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy
| | - Rocco Micciolo
- Department of Psychology and Cognitive Sciences, University of Trento, Trento, Italy
| | - Marta Camilot
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy
| | - Franco Antoniazzi
- Pediatric Division, Department of Pediatrics, University Hospital of Verona, Verona, Italy.,Regional Center for the diagnosis and treatment of children and adolescents rare skeletal disorders, Pediatric Clinic, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
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18
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Tanaka M, Enatsu N, Chiba K, Fujisawa M. Two cases of reversible male infertility due to congenital adrenal hyperplasia combined with testicular adrenal rest tumor. Reprod Med Biol 2018; 17:93-97. [PMID: 29371828 PMCID: PMC5768970 DOI: 10.1002/rmb2.12068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/03/2017] [Indexed: 11/12/2022] Open
Abstract
Cases Testicular adrenal rest tumor (TART) is one of the possible causes of male infertility, accompanied by congenital adrenal hyperplasia (CAH). Here are reported two cases of TARTs that were referred to Kobe City Medical Center West Hospital for the treatment of infertility and testicular tumors. Outcome In one case, the semen analysis was improved from oligoasthenozoospermia to normozoospermia after taking oral glucocorticoid supplementation. The other case of original azoospermia showed that sperm had ejaculated into the semen after taking oral glucocorticoid supplementation. Conclusion Although the prevalence of TARTs in male infertility is very rare, it is important to know how to approach this disease, considering the curable pathology of spermatogenesis and tumors resembling an appearance to germ cell tumors.
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Affiliation(s)
- Mikito Tanaka
- Department of UrologyKobe University Graduate School of MedicineKobe CityJapan
| | - Noritoshi Enatsu
- Division of UrologyKobe City Medical Center West HospitalKobe CityJapan
| | - Koji Chiba
- Department of UrologyKobe University Graduate School of MedicineKobe CityJapan
| | - Masato Fujisawa
- Department of UrologyKobe University Graduate School of MedicineKobe CityJapan
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19
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Mendoza-Rojas VC, Díaz-Martínez LA, Mantilla-Mora G, Contreras-García GA, Mora-Bautista VM, Martínez-Paredes JF, Calderón-Rojas AL, Gómez-Tarazona CA, Pinzón-Mantilla K. 17-hydroxiprogesterone values in healthy preterm infants. COLOMBIA MEDICA (CALI, COLOMBIA) 2017; 48:161-166. [PMID: 29662257 PMCID: PMC5896722 DOI: 10.25100/cm.v43i4.2983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Introduction: In preterm newborn, problems with the interpretation of 17-OHP may occur. Objective: Evaluate 17-OHP values in healthy preterm newborns until they reach the corrected gestational age. Methods: Longitudinal study of 36 preterm infants with 17-OHP evaluation using ELISA from heel blood from 3 to 5 days and thereafter every 2 weeks until the corrected gestational age. Values adjusting multiple variables such as gestational age, birth weight and sex, among others were compared. The results were analyzed against 82 healthy full-term infants. Results: In the first week of life, early term infants born within less than 34 months of gestational age show 17-OHP values that are much higher than the full term neonates. After a week, the values decrease and stabilize, but are still higher than those of full term neonates and remain so even at the corrected gestational age. (average difference of 63.0%, CI 95%: 11.8%-115.5%). 33.6% (41 samples) of a total of 122 samples taken from preterm infants were higher than 30 ng/mL. Conclusions: 17-OHP values in early term infants are higher than those in full term neonates and can be related to postnatal adaptive processes. It is suggested that a second screening at the 37th week of corrected age be performed.
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Affiliation(s)
| | | | - Gerardo Mantilla-Mora
- Escuela de Medicina, Facultad de Salud, Universidad Industrial de Santander, Bucaramanga, Colombia
| | | | - Víctor Manuel Mora-Bautista
- Programa de Especialización en Pediatría, Departamento de Pediatría, Escuela de Medicina; Facultad de Salud, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Jhon Freddy Martínez-Paredes
- Programa de Medicina, Escuela de Medicina, Facultad de Salud, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Alba Luz Calderón-Rojas
- Programa de Medicina, Escuela de Medicina, Facultad de Salud, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Carlos Augusto Gómez-Tarazona
- Programa de Medicina, Escuela de Medicina, Facultad de Salud, Universidad Industrial de Santander, Bucaramanga, Colombia
| | - Katherine Pinzón-Mantilla
- Programa de Microbiología y Bioanálisis, Escuela de Microbiología, Facultad de Salud, Universidad Industrial de Santander, Bucaramanga, Colombia
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20
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Hayashi GY, Carvalho DF, de Miranda MC, Faure C, Vallejos C, Brito VN, Rodrigues ADS, Madureira G, Mendonca BB, Bachega TASS. Neonatal 17-hydroxyprogesterone levels adjusted according to age at sample collection and birthweight improve the efficacy of congenital adrenal hyperplasia newborn screening. Clin Endocrinol (Oxf) 2017; 86:480-487. [PMID: 27978607 DOI: 10.1111/cen.13292] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 11/04/2016] [Accepted: 12/07/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The primary concern related to congenital adrenal hyperplasia (CAH) newborn screening (NBS) is the high rate of false-positive results (FPR) associated with prematurity; false-negative results (FNR) can also occur due to precocious sample collection. OBJECTIVE To determine the neonatal 17-hydroxyprogesterone (N17OHP) normal range in newborns in Sao Paulo using different references according to age and birthweight (BW) and to establish the optimal NBS cut-off levels. METHODS Neonatal 17-hydroxyprogesterone levels from 271 810 newborns (NBs) according to sample collection time (G1: 48-<72 h and G2: ≥72 h) and BW (≤1500 g, 1501-2000 g, 2001-2500 and >2500 g) were evaluated. N17OHP was measured by an fluoroimmunoassay, and serum 17OHP was measured by liquid chromatography-mass spectrometry. Affected and asymptomatic NBs with persistently increased 17OHP levels were submitted to CYP21A2-sequencing. RESULTS Neonatal 17-hydroxyprogesterone levels in G1 were lower than G2 in all BW groups (P < 0·001). The FPR rate in G1/G2 was 0·2% using the 99·8th and 0·5% using the 99·5th percentile. The 99·8th percentile N17OHP value was the best cut-off for distinguishing between unaffected and affected NBs. Forty-four salt wasters, and five simple virilisers were diagnosed; N17OHP levels ranged from 93·3 to 2209·8 nmol/l, and no affected neonates with FNR were identified. The positive predictive value in G1 and G2 using the 99·8th percentile was 5·6% and 14·1%, respectively, and 2·3% and 7%, respectively, using the 99·5th percentile. Molecular tests identified two NBs with the nonclassical form among the 29 FPR. CONCLUSION Neonatal 17-hydroxyprogesterone levels adjusted to sample collection age and birthweight reduced the FPR, and the use of N17OHP values based upon the 99·8th percentile improved the NBS efficacy.
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Affiliation(s)
- Giselle Y Hayashi
- Associação de Pais e Amigos dos Excepcionais de São Paulo - APAE DE SÃO PAULO, São Paulo, Brazil
- Laboratório de Hormônios e Genética Molecular/LIM 42 - Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Daniel F Carvalho
- Laboratório de Hormônios e Genética Molecular/LIM 42 - Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Mirela C de Miranda
- Laboratório de Hormônios e Genética Molecular/LIM 42 - Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Cláudia Faure
- Associação de Pais e Amigos dos Excepcionais de São Paulo - APAE DE SÃO PAULO, São Paulo, Brazil
| | - Carla Vallejos
- Associação de Pais e Amigos dos Excepcionais de São Paulo - APAE DE SÃO PAULO, São Paulo, Brazil
| | - Vinícius N Brito
- Laboratório de Hormônios e Genética Molecular/LIM 42 - Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Andresa De Santi Rodrigues
- Laboratório de Hormônios e Genética Molecular/LIM 42 - Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Guiomar Madureira
- Laboratório de Hormônios e Genética Molecular/LIM 42 - Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Laboratório de Hormônios e Genética Molecular/LIM 42 - Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Tânia A S S Bachega
- Laboratório de Hormônios e Genética Molecular/LIM 42 - Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Neonatal screening for congenital adrenal hyperplasia in Southern Brazil: a population based study with 108,409 infants. BMC Pediatr 2017; 17:22. [PMID: 28095810 PMCID: PMC5240440 DOI: 10.1186/s12887-016-0772-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 12/30/2016] [Indexed: 12/01/2022] Open
Abstract
Background Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder associated with inborn errors of steroid metabolism. 21-hydroxylase enzyme deficiency occurs in 90 to 95% of all cases of CAH, with accumulation of 17 hydroxyprogesterone (17-OHP). Early diagnosis of CAH based on newborn screening is possible before the development of symptoms and allows proper treatment, correct sex assignment, and reduced mortality rates. This study describes the results obtained in the first year of a public CAH screening program in the state of Rio Grande do Sul, Brazil. Methods We reviewed the screening database in search of babies with suspected CAH, that is, altered birth-weight adjusted 17-OHP values at screening. The following data were analyzed for this population: screening 17-OHP values, retest 17-OHP values, serum 17-OHP values for those with confirmed CAH on retest, maternal and newborn data, and family history of CAH. For the screening program, 17-OHP levels are determined on dried blood spots obtained in filter paper with GSP solid phase time-resolved immunofluorescence. Results Of 108,409 newborns screened, eight were diagnosed with CAH (four males, four females). The incidence of CAH in the state was 1:13,551. Six cases were identified as classic salt-wasting CAH and two were cases of virilizing CAH. The positive predictive value (PPV) of the initial screening (before diagnostic confirmation) was 1.6%. The overall rate of false positive results was 0.47%. The number of false positive results was higher among newborns with birth weight < 2000 g. Conclusion The present results support the need for CAH screening by the public health care system in the state, and show that the strategy adopted is adequate. PPV and false positive results were similar to those reported for other states of Brazil with similar ethnic backgrounds.
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The influence of seasonality and manufacturer kit lot changes on 17α-hydroxyprogesterone measurements and referral rates of congenital adrenal hyperplasia in newborns. Eur J Pediatr 2017; 176:121-129. [PMID: 27900477 DOI: 10.1007/s00431-016-2814-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/14/2016] [Accepted: 11/16/2016] [Indexed: 11/27/2022]
Abstract
UNLABELLED Newborn screening for congenital adrenal hyperplasia (CAH) is performed by measuring the concentration of 17α-hydroxyprogesterone (17-OHP) in dried blood spots. Unfortunately, the level of 17-OHP varies due to multiple factors, and therefore, the false positive rate for the test is a challenge. We analyzed screening data from 2007 to 2015 to determine the effect of seasonal changes and manufacturer kit lot changes on 17-OHP values and on numbers of infants referred. Data from screening 2.2 million infants over a 9-year period indicates that in the NYS during the colder months, daily mean 17-OHP values are higher, more retests are performed, and more infants are referred even though fewer infants are born. The practice of using fixed cutoffs for referring infants for CAH leads to more false positive results in colder months. In addition, there was an overall 10% increase in the daily mean 17-OHP values from the 2 years before and after a manufacturer kit lot change that occurred in November 2013, suggestive of a functional change in the kit at that time. CONCLUSION Newborn screening programs should be cognizant of seasonal temperature variations and (un)anticipated manufacturer kit changes because they may affect 17-OHP values and CAH referral rates. What is Known: • Newborn screening for congenital adrenal hyperplasia is generally performed by measuring 17α-hydroxyprogesterone (17-OHP) levels in dried blood spots. • 17-OHP concentrations are affected by gestational age/weight of infant when specimen is collected, specimen collection time after birth, as well as race and sex of infant. What is New: • Seasonal temperature variations and unanticipated manufacturer kit changes affect 17-OHP levels and consequently referral rates in programs that use fixed cutoffs. • Daily mean 17-OHP is generally higher when the ambient temperature is lower.
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Parsa AA, New MI. Steroid 21-hydroxylase deficiency in congenital adrenal hyperplasia. J Steroid Biochem Mol Biol 2017; 165:2-11. [PMID: 27380651 DOI: 10.1016/j.jsbmb.2016.06.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 06/26/2016] [Accepted: 06/30/2016] [Indexed: 02/09/2023]
Abstract
Congenital adrenal hyperplasia (CAH) refers to a group of inherited genetic disorders involving deficiencies in enzymes that convert cholesterol to cortisol within the adrenal cortex. There are five key enzymes involved in the production of cortisol. Of these key enzymes, deficiency of 21-hydroxylase is the most commonly defective enzyme leading to CAH representing more than 90% of cases. The low adrenal cortisol levels associated with CAH affects the hypothalamic-pituitary-adrenal negative feedback system leading to increased pituitary adrenocorticotropic hormone (ACTH) production, which overstimulates the adrenal cortex in an attempt to increase cortisol production resulting in a hyperplastic adrenal cortex. The deficiency of enzyme 21-hydroxylase results from mutations or deletions in the CYP21A2 gene found on chromosome 6p. The disorder is transmitted as an autosomal recessive pattern and specific mutations may be correlated to enzymatic compromise of varying degrees, leading to the clinical manifestation of 21-hydroxylase deficiency (21-OHD) CAH.
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Affiliation(s)
- Alan A Parsa
- Department of Medicine, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii, United States.
| | - Maria I New
- Adrenal Steroid Disorders Program, Icahn School of Medicine at Mount Sinai, Manhattan, NY, United States
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24
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Pearce M, DeMartino L, McMahon R, Hamel R, Maloney B, Stansfield DM, McGrath EC, Occhionero A, Gearhart A, Caggana M, Tavakoli NP. Newborn screening for congenital adrenal hyperplasia in New York State. Mol Genet Metab Rep 2016; 7:1-7. [PMID: 27331001 PMCID: PMC4908061 DOI: 10.1016/j.ymgmr.2016.02.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 02/19/2016] [Accepted: 02/20/2016] [Indexed: 11/17/2022] Open
Abstract
From 2007 to 2014 the New York State (NYS) Newborn Screening (NBS) program screened 2 million newborns for congenital adrenal hyperplasia (CAH). The data was analyzed to determine factors that affect 17α-hydroxyprogesterone levels and assist in developing algorithm changes that would improve the positive predictive value of the methodology being used. The concentration of 17-OHP in dried blood spots was measured using the AutoDELFIA Neonatal 17-OHP kit (Perkin Elmer, Turku, Finland). During the 8 year period of this study 2476 babies were referred, 105 babies were diagnosed with CAH (90 with the salt-wasting (SW), 8 with simple virilizing (SV), 5 with non-classical CAH, and 2 with another enzyme deficiency) and, 14 with possible CAH. Three false negative cases with SV-CAH were reported to the program. Of the total 108 known cases, 74 (69%) infants were detected by newborn screening in the absence of clinical information, or, known family history. The incidence of CAH in NYS is 1 in 18,170 with a ratio of SW to SV of 8.2:1. The incidence of CAH is lower in Black infants than in White, Hispanic and Asian infants. Despite a lower mean birth weight, female infants have a lower mean 17-OHP value than male infants and are under-represented in the referred category. As per other NBS programs the false positive rate is exacerbated by prematurity/low birth weight and by over-early specimen collection.
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Affiliation(s)
- Melissa Pearce
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Lenore DeMartino
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rebecca McMahon
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Rhonda Hamel
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Breanne Maloney
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | | | - Emily C McGrath
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Amanda Occhionero
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Adam Gearhart
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Michele Caggana
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Norma P Tavakoli
- Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, NY, USA; Department of Biomedical Sciences, School of Public Health, State University of New York, Albany, NY, USA
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Tajima T, Fukushi M. Neonatal mass screening for 21-hydroxylase deficiency. Clin Pediatr Endocrinol 2016; 25:1-8. [PMID: 26865749 PMCID: PMC4738187 DOI: 10.1297/cpe.25.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/13/2015] [Indexed: 11/27/2022] Open
Abstract
Congenital adrenal hyperplasia(CAH)due to 21-hydroxylase deficiency (21-OHD) is an
inherited autosomal recessive disorder. Its incidence is 1 in 10,000 to 20,000 worldwide.
This disease shows phenotypic differences, and it is divided into three forms i.e., the
salt wasting (SW), simple virilizing (SV), and nonclassic (NC) forms. The most severe form
of SW manifests in the first months of life with life-threatening adrenal insufficiency,
leading to death. To prevent death by adrenal insufficiency in neonates with the SW form
and wrong gender assignment of 46,XX female patients with SW and SV, neonatal mass
screening of 21-OHD is performed in several countries including Japan. However, the
positive predictive value (PPV) remains low, especially in preterm infants. To reduce the
false positive rate and increase the PPV, liquid chromatography followed by tandem mass
spectrometry (LC-MS/MS) as a second-tier test may be useful. In this review, the current
knowledge on neonatal mass screening of 21-OHD is summarized.
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Affiliation(s)
- Toshihiro Tajima
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan; Present: Jichi Children's Medical Center Tochigi, Shimotsuke, Japan
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Tsuji A, Konishi K, Hasegawa S, Anazawa A, Onishi T, Ono M, Morio T, Kitagawa T, Kashimada K. Newborn screening for congenital adrenal hyperplasia in Tokyo, Japan from 1989 to 2013: a retrospective population-based study. BMC Pediatr 2015; 15:209. [PMID: 26671474 PMCID: PMC4681082 DOI: 10.1186/s12887-015-0529-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) cause life-threatening adrenal crisis. It also affects fetal sex development and can result in incorrect sex assignment at birth. In 1989, a newborn screening program for congenital adrenal hyperplasia (CAH) was introduced in Tokyo. Here we present the results of this screening program in order to clarify the efficiency of CAH screening and the incidence of CAH in Japan. METHOD From 1989 to 2013, a total of 2,105,108 infants were screened for CAH. The cutoff level for diagnosis of CAH was adjusted for gestational age and birth weight. RESULTS A total of 410 infants were judged positive, and of these, 106 patients were diagnosed with CAH, indicating a positive predictive value (PPV) of 25.8 %. Of the 106 patients, 94 (88.7 %) were diagnosed with 21-OHD. Of these 94 patients, 73 were diagnosed with the salt wasting form, 14 with the simple virilising form and 7 with the nonclassical form (NC21OHD). The mean birth weight and gestational age were 3192 ± 385 g and 38.9 ± 1.38 weeks. 11 out of 44 female patients were assigned as female according to their screening result. CONCLUSIONS These data suggest that the newborn screening in Tokyo was effective, especially for sex assignment and preventing fatal adrenal crisis. The incidence of CAH was similar to that measured in previous Japanese screening studies, and it was also similar to that of western countries. The incidence of NC21OHD in Japan in the present study was lower than that in western countries as previous studies reported. The screening program achieved higher PPV than previous CAH screening studies, which might be due to the use of variable cutoffs according to gestational age and birth weight. However, most of the neonates born at 37 weeks or less that were referred to hospital were false-positives. Further changes are needed to reduce the number of false positive preterm neonates.
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Affiliation(s)
- Atsumi Tsuji
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Kaoru Konishi
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
| | - Satomi Hasegawa
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
| | - Akira Anazawa
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
| | - Toshikazu Onishi
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan. .,Kinki Central Hospital, Hyogo, Japan.
| | - Makoto Ono
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Teruo Kitagawa
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan. .,Tokyo Health Service Association, Newborn Screening, Tokyo, Japan.
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27
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Held PK, Shapira SK, Hinton CF, Jones E, Hannon WH, Ojodu J. Congenital adrenal hyperplasia cases identified by newborn screening in one- and two-screen states. Mol Genet Metab 2015; 116:133-8. [PMID: 26296712 PMCID: PMC4640991 DOI: 10.1016/j.ymgme.2015.08.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 11/28/2022]
Abstract
There is no clear consensus among state newborn screening programs on whether routine second screening of newborns identifies clinically relevant cases of congenital adrenal hyperplasia. This retrospective study evaluated laboratory practices, along with biochemical and medical characteristics of congenital adrenal hyperplasia (CAH) cases (1) detected on the first newborn screen in one-screen compared to two-screen states, and (2) detected on the first versus the second screen in the two-screen states, to determine the effectiveness of a second screen. A total of 374 confirmed cases of CAH from 2 one-screen states and 5 two-screen states were included in this study. Demographic data and diagnostic information on each reported case were collected and analyzed. Additionally, laboratory data, including screening methodologies and algorithms, were evaluated. The one-screen states reported 99 cases of CAH out of 1,740,586 (1 in 17,500) newborns screened: 88 (89%) identified on the first screen and 5 (5%) identified on the targeted second screen. The two-screen states reported 275 cases of CAH out of 2,629,627 (1 in 9500) newborns screened: 165 (60%) identified on the first screen and 99 (36%) identified on the second screen. Using a multivariate model, the only significant predictor of whether a case was identified on the first or the second screen in the two-screen states was the type of CAH. Compared with classical salt-wasting CAH, classical simple virilizing and non-classical CAH cases were less likely to be detected on the first versus the second screen. The routine second newborn screen is important for identifying children with CAH, particularly simple virilizing and non-classical forms, which might otherwise not be captured through a single screen.
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Affiliation(s)
- Patrice K Held
- Wisconsin State Laboratory of Hygiene, University of Wisconsin, Madison, WI, USA.
| | - Stuart K Shapira
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Cynthia F Hinton
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Elizabeth Jones
- Newborn Screening and Genetics Program, Association of Public Health Laboratories, Silver Spring, MD, USA
| | - W Harry Hannon
- Division of Laboratory Sciences, Centers for Disease Control and Prevention (retired), Atlanta, GA, USA
| | - Jelili Ojodu
- Newborn Screening and Genetics Program, Association of Public Health Laboratories, Silver Spring, MD, USA
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Ishii T, Anzo M, Adachi M, Onigata K, Kusuda S, Nagasaki K, Harada S, Horikawa R, Minagawa M, Minamitani K, Mizuno H, Yamakami Y, Fukushi M, Tajima T. Guidelines for diagnosis and treatment of 21-hydroxylase deficiency (2014 revision). Clin Pediatr Endocrinol 2015; 24:77-105. [PMID: 26594092 PMCID: PMC4639531 DOI: 10.1297/cpe.24.77] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 03/10/2015] [Indexed: 11/07/2022] Open
Abstract
Purpose of developing the guidelines: The first guidelines for diagnosis and treatment of
21-hydroxylase deficiency (21-OHD) were published as a diagnostic handbook in Japan in
1989, with a focus on patients with severe disease. The “Guidelines for Treatment of
Congenital Adrenal Hyperplasia (21-Hydroxylase Deficiency) Found in Neonatal Mass
Screening (1999 revision)” published in 1999 were revised to include 21-OHD patients with
very mild or no clinical symptoms. Accumulation of cases and experience has subsequently
improved diagnosis and treatment of the disease. Based on these findings, the Mass
Screening Committee of the Japanese Society for Pediatric Endocrinology further revised
the guidelines for diagnosis and treatment. Target disease/conditions: 21-hydroxylase
deficiency. Users of the guidelines: Physician specialists in pediatric endocrinology,
pediatric specialists, referring pediatric practitioners, general physicians; and
patients.
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Affiliation(s)
| | | | | | - Tomohiro Ishii
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Anzo
- Department of Pediatrics, Kawasaki City Hospital, Kanagawa, Japan
| | - Masanori Adachi
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Kazumichi Onigata
- Shimane University Hospital Postgraduate Clinical Training Center, Shimane, Japan
| | - Satoshi Kusuda
- Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Keisuke Nagasaki
- Division of Pediatrics, Department of Homeostatic Regulation and Development, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Shohei Harada
- Division of Neonatal Screening, National Center for Child Health and Development, Tokyo, Japan
| | - Reiko Horikawa
- Department of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | | | - Kanshi Minamitani
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Haruo Mizuno
- Departments of Pediatrics and Neonatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yuji Yamakami
- Kanagawa Health Service Association, Kanagawa, Japan
| | | | - Toshihiro Tajima
- Department of Pediatrics, Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
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Abi Salloum B, Veiga-Lopez A, Abbott DH, Burant CF, Padmanabhan V. Developmental programming: exposure to testosterone excess disrupts steroidal and metabolic environment in pregnant sheep. Endocrinology 2015; 156:2323-37. [PMID: 25763641 PMCID: PMC4430607 DOI: 10.1210/en.2014-2006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Gestational exposure to excess T leads to intrauterine growth restriction, low birth weight, and adult metabolic/reproductive disorders in female sheep. We hypothesized that as early mediators of such disruptions, gestational T disrupts steroidal and metabolic homeostasis in both the mother and fetus by both androgenic and metabolic pathways. Maternal blood samples were measured weekly for levels of insulin, glucose, and progesterone from four groups of animals: control; gestational T (twice weekly im injections of 100 mg of T propionate from d 30 to d 90 of gestation); T plus an androgen antagonist, flutamide (15 mg/kg·d oral; T-Flutamide); and T plus the insulin sensitizer, rosiglitazone (0.11 mg/kg·d oral; T-Rosi) (n = 10-12/group). On day 90 of gestation, maternal and umbilical cord samples were collected after a 48-hour fast from a subset (n = 6/group) for the measurement of steroids, free fatty acids, amino acids, and acylcarnitines. Gestational T decreased maternal progesterone levels by 36.5% (P < .05), which was prevented by flutamide showing direct androgenic mediation. Gestational T also augmented maternal insulin levels and decreased medium chained acylcarnitines, suggesting increased mitochondrial fatty acid oxidation. These changes were prevented by rosiglitazone, suggesting alterations in maternal fuel use. Gestational T-induced increases in fetal estradiol were not prevented by either cotreatment. Gestational T disrupted associations of steroids with metabolites and progesterone with acylcarnitines, which was prevented either by androgen antagonist or insulin sensitizer cotreatment. These findings suggest a future combination of these treatments might be required to prevent alteration in maternal/fetal steroidal and metabolic milieu(s).
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Affiliation(s)
- B Abi Salloum
- Departments of Pediatrics (B.A.S., A.V.-L., V.P.) and Internal Medicine (C.F.B.) and Reproductive Sciences Program (V.P.), University of Michigan, Ann Arbor, Michigan 48109; and Department of Obstetrics and Gynecology and Wisconsin National Primate Research Center (D.H.A.), University of Wisconsin, Madison, Wisconsin 53706
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Abstract
Newborn screening is a major aspect of public health success. Babies in every state are tested for a recommended uniform screening panel of conditions not otherwise immediately evident in the first days of life. With the goal of reducing morbidity and mortality, conditions should be added to newborn screening panels using a scientific, evidence-based process. Newborn screening is a system involving partners at many levels; neonatologists have a special role in ensuring that their vulnerable patients also receive this life-saving test. Careful attention to the social, legal, and ethical aspects will help increase the scope of newborn screening.
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Sarafoglou K, Gaviglio A, Hietala A, Frogner G, Banks K, McCann M, Thomas W. Comparison of newborn screening protocols for congenital adrenal hyperplasia in preterm infants. J Pediatr 2014; 164:1136-40. [PMID: 24582106 DOI: 10.1016/j.jpeds.2014.01.038] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 12/03/2013] [Accepted: 01/17/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare 2 screening protocols performed concurrently in Minnesota: (1) liquid chromatography tandem mass spectrometry steroid profiling as a second-tier test on positive fluoroimmunoassay (FIA) results; and (2) low-birthweight 3-screen protocol (FIA tests at <48 hours, 2 weeks, 4 weeks) on all infants <1800 g, regardless of result. STUDY DESIGN Population-based study of all <1800 g infants (n = 8739) born in Minnesota from 2004-2010 comparing newborn screening performance metrics of 2-tier (FIA + liquid chromatography tandem mass spectrometry) protocol (2004-2010) vs 1-tier (FIA) low-birthweight 3-screen protocol (2006-2010). False positive (FP) rates were calculated per infant's final confirmatory result. Protocol results used in different time periods (2004-2005 vs 2006-2010) were compared by 2-sample tests of proportions; results of both protocols for 2006-2010 were compared by McNemar test. RESULTS First-tier testing of final dried blood spot result (n = 6625) of the low-birthweight 3-screen protocol during 2006-2010 reduced the FP rate more than 5-fold (P < .0001) compared with 2-tier testing of a single dried blood spot (n = 2114) from 2004-2005. In comparing results (n = 6625) of both protocols from 2006-2010, first-tier testing of final dried blood spot accounted for 23% of FPs; second-tier testing of the first dried blood spot accounted for 77%, yielding significantly more FP results (McNemar test, P < .0001). CONCLUSION Timing of dried blood spot collection rather than assay used played a more important role in reducing FP results of congenital adrenal hyperplasia newborn screening in low birthweight infants.
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Affiliation(s)
- Kyriakie Sarafoglou
- Division of Pediatric Endocrinology, Division of Genetics and Metabolism, Department of Pediatrics, University of Minnesota Amplatz Children's Hospital, Minneapolis, MN.
| | | | - Amy Hietala
- Minnesota Department of Health, St. Paul, MN
| | | | | | - Mark McCann
- Minnesota Department of Health, St. Paul, MN
| | - William Thomas
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
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Morikawa S, Nakamura A, Fujikura K, Fukushi M, Hotsubo T, Miyata J, Ishizu K, Tajima T. Results from 28 years of newborn screening for congenital adrenal hyperplasia in sapporo. Clin Pediatr Endocrinol 2014; 23:35-43. [PMID: 24790385 PMCID: PMC4004996 DOI: 10.1297/cpe.23.35] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 12/16/2013] [Indexed: 11/04/2022] Open
Abstract
The primary goal of newborn mass screening (MS) for congenital adrenal hyperplasia (CAH) is the prevention of life-threatening salt-wasting crisis in the most severe forms of CAH, and MS for CAH has been implemented in several countries. We summarize here our experience and results from newborn CAH MS from 1982 to 2010 in Sapporo City. During these 28 yr, the level of 17-hydroxyprogesterone (17-OHP) was determined in MS of samples from 498,147 newborns. During this period, 26 individuals (19 females and 7 males) with 21-hydroxylase deficiency (21-OHD) were detected. Of the 26 CAH, 20 were classified as having the salt-wasting (SW) form, 4 were classified as having the simple virilizing (SV) form, and 2 were classified as having the noncalssic (NC) form. Therefore, the frequency of the classical type of CAH was 1 in 20,756. In order to improve the effectiveness, we employed high-performance liquid chromatography (HPLC) as a second tier test from 2000. During this period, among the recalled babies, 75.4% were born prior to the 37th wk of gestation age, and the recall rate was 5.38% for premature neonates and 0.06% for mature neonates. MS for CAH in Sapporo is effective for the identification of the SW and SV forms of 21-OHD. However, the recall rate of premature babies is still high after the introduction of HPLC as a second tier test.
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Affiliation(s)
- Shuntaro Morikawa
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
| | - Akie Nakamura
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
| | | | | | - Tomoyuki Hotsubo
- Department of Pediatrics, NTT East Japan Sapporo Hospital, Sapporo, Japan
| | - Jun Miyata
- Sapporo City Institute of Public Health, Sapporo, Japan
| | - Katsura Ishizu
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
| | - Toshihiro Tajima
- Department of Pediatrics, Hokkaido University School of Medicine, Sapporo, Japan
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[Do we need congenital adrenal hyperplasia screening for premature infants?]. Arch Pediatr 2013; 21:233-6. [PMID: 24361036 DOI: 10.1016/j.arcped.2013.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 11/17/2013] [Accepted: 11/19/2013] [Indexed: 11/23/2022]
Abstract
Congenital adrenal hyperplasia neonatal screening has been introduced in France since 1995. A recent survey has questioned its relevance in premature infants because of a high number of false positives and a low positive predictive value of 17-hydroxyprogesterone dosage. A workgroup at the French screening association (Association française de dépistage et de prévention des handicaps de l'enfant) collected all the epidemiological, clinical and biological data of premature children presenting with adrenal hyperplasia from the national cohort. Their results were compared with those of healthy premature children. All the data showed that the screening in children born before 32 weeks of gestational age is irrelevant, but that it is efficient after this term. A pilot study has been implemented in population to evaluate the opportunity to discontinue this screening in extreme preterm neonates.
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Koh JW, Kim GH, Yoo HW, Yu J. Clinical features of congenital adrenal insufficiency including growth patterns and significance of ACTH stimulation test. J Korean Med Sci 2013; 28:1650-6. [PMID: 24265530 PMCID: PMC3835509 DOI: 10.3346/jkms.2013.28.11.1650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 09/05/2013] [Indexed: 12/18/2022] Open
Abstract
Congenital adrenal insufficiency is caused by specific genetic mutations. Early suspicion and definite diagnosis are crucial because the disease can precipitate a life-threatening hypovolemic shock without prompt treatment. This study was designed to understand the clinical manifestations including growth patterns and to find the usefulness of ACTH stimulation test. Sixteen patients with confirmed genotyping were subdivided into three groups according to the genetic study results: congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH, n=11), congenital lipoid adrenal hyperplasia (n=3) and X-linked adrenal hypoplasia congenita (n=2). Bone age advancement was prominent in patients with CAH especially after 60 months of chronologic age (n=6, 67%). They were diagnosed in older ages in group with bone age advancement (P<0.05). Comorbid conditions such as obesity, mental retardation, and central precocious puberty were also prominent in this group. In conclusion, this study showed the importance of understanding the clinical symptoms as well as genetic analysis for early diagnosis and management of congenital adrenal insufficiency. ACTH stimulation test played an important role to support the diagnosis and serum 17-hydroxyprogesterone levels were significantly elevated in all of the CAH patients. The test will be important for monitoring growth and puberty during follow up of patients with congenital adrenal insufficiency.
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MESH Headings
- 17-alpha-Hydroxyprogesterone/blood
- Adolescent
- Adrenal Hyperplasia, Congenital/drug therapy
- Adrenal Hyperplasia, Congenital/genetics
- Adrenal Insufficiency/congenital
- Adrenal Insufficiency/diagnosis
- Adrenal Insufficiency/drug therapy
- Adrenal Insufficiency/genetics
- Adrenocorticotropic Hormone/metabolism
- Bone Development/genetics
- Child
- Child, Preschool
- DAX-1 Orphan Nuclear Receptor/genetics
- Disorder of Sex Development, 46,XY/drug therapy
- Disorder of Sex Development, 46,XY/genetics
- Female
- Genetic Diseases, X-Linked/drug therapy
- Genetic Diseases, X-Linked/genetics
- Genotype
- Glucocorticoids/therapeutic use
- Humans
- Hypoadrenocorticism, Familial
- Intellectual Disability/complications
- Male
- Mineralocorticoids/therapeutic use
- Obesity/complications
- Phosphoproteins/genetics
- Puberty, Precocious/complications
- Retrospective Studies
- Steroid 21-Hydroxylase/genetics
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Affiliation(s)
- Ji Won Koh
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
| | - Gu Hwan Kim
- Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Han Wook Yoo
- Medical Genetics Center, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeesuk Yu
- Department of Pediatrics, Dankook University College of Medicine, Cheonan, Korea
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Aycan Z, Bas VN, Cetinkaya S, Yilmaz Agladioglu S, Tiryaki T. Prevalence and long-term follow-up outcomes of testicular adrenal rest tumours in children and adolescent males with congenital adrenal hyperplasia. Clin Endocrinol (Oxf) 2013; 78:667-72. [PMID: 23057653 DOI: 10.1111/cen.12033] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 08/13/2012] [Accepted: 09/03/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE There are a few studies regarding the prevalence of testicular adrenal rest tumours (TARTs) in boys and adolescent males with congenital adrenal hyperplasia (CAH), and there is little information regarding the treatment outcomes in patients with TARTs. The aim of this study was to determine the long-term treatment outcomes in boys and adolescent males with CAH. PATIENTS AND METHODS Sixty boys and adolescent males with CAH, who were between 2 and 18 years of age, were included in the study. Fifty-five patients had 21-hydroxylase deficiency (21-OHD), and five patients had 11-β hydroxylase deficiency (11β-OHD). All patients were screened for TARTs by scrotal ultrasonography (US) performed by an experienced radiologist. RESULTS TART prevalence was 18·3% in 2-18 years' of age; eight patients had 21-OHD, and three had 11β-OHD. The youngest patient with TART was 4 years old, whereas eight patients with RTs were at puberty. Only two patients had tight metabolic control: eight patients had stage 2, one had stage 4, and two had stage five rest tumours. In four patients with stage 2 TARTs, tumours disappeared after high-dose steroid treatment and did not recur. Shrinkage of tumour was observed in two patients. Testis-sparing surgery was performed in one patient with stage five tumour. Gonadal functions were normal in patients with partially regressed tumours. Two patients became fathers of healthy male off-springs. CONCLUSIONS Detection and treatment for TARTs in children with CAH at younger ages, earlier stages, may prevent infertility in adulthood. Therefore, we recommend that scrotal US screening should be performed in every 1-2 years starting from early childhood.
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Affiliation(s)
- Zehra Aycan
- Clinics of Pediatric Endocrinology, School of Medicine, Yıldırım Beyazıt University, Ankara, Turkey
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González EC, Carvajal F, Frómeta A, Arteaga AL, Castells EM, Espinosa T, Coto R, Pérez PL, Tejeda Y, Del Río L, Segura MT, Almenares P, Robaina R, Fernández JL. Newborn screening for congenital adrenal hyperplasia in Cuba: six years of experience. Clin Chim Acta 2013; 421:73-8. [PMID: 23481450 DOI: 10.1016/j.cca.2013.02.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 02/18/2013] [Accepted: 02/19/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Since 2005, a newborn screening program for congenital adrenal hyperplasia (CAH) by measuring 17-alpha-hydroxyprogesterone (17OHP) in dried blood spots was introduced in Cuba. METHODS The hormone was measured by the 17OHP Neonatal UMELISA method, in samples collected on the 5th day as average. Confirmatory test was performed to those neonates with 17OHP values above 55 nmol/l. Some perinatal factors that can influence on 17OHP levels were studied. RESULTS From January 2005 to December 2010, 621,303 newborns were screened and 39 CAH cases were detected. Coverage of the program reached 98%. The incidence of CAH in Cuba was 1:15,931, similar to that reported by other programs. A recall for suspected CAH was performed in 10,799 cases (1.74%). Therapy in classical CAH patients was started at the mean age of 22 days. 17OHP levels were significantly higher in newborns with lower birth-weight (BW) and/or gestational age (GA). In addition, 17OHP values were affected by the gender, twin status or mode of delivery. CONCLUSIONS In Cuba, the nationwide newborn screening program has allowed the early detection of CAH. The use of an optimized cut-off level for BW or GA could lead to a reduction in the percentage of recalled babies.
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Sarafoglou K, Banks K, Gaviglio A, Hietala A, McCann M, Thomas W. Comparison of one-tier and two-tier newborn screening metrics for congenital adrenal hyperplasia. Pediatrics 2012; 130:e1261-8. [PMID: 23071209 DOI: 10.1542/peds.2012-1219] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Newborn screening (NBS) for the classic forms of congenital adrenal hyperplasia (CAH) is mandated in all states in the United States. Compared with other NBS disorders, the false-positive rate (FPR) of CAH screening remains high and has not been significantly improved by adjusting 17α-hydroxyprogesterone cutoff values for birth weight and/or gestational age. Minnesota was the first state to initiate, and only 1 of 4 states currently performing, second-tier steroid profiling for CAH. False-negative rates (FNRs) for CAH are not well known. METHODS This is a population-based study of all Minnesota infants (769,834) born 1999-2009, grouped by screening protocol (one-tier with repeat screen, January 1999 to May 2004; two-tier with second-tier steroid profiling, June 2004 to December 2009). FPR, FNR, and positive predictive value (PPV) were calculated per infant, rather than per sample, and compared between protocols. RESULTS Overall, 15 false-negatives (4 salt-wasting, 11 simple-virilizing) and 45 true-positives were identified from 1999 to 2009. With two-tier screening, FNR was 32%, FPR increased to 0.065%, and PPV decreased to 8%, but these changes were not statistically significant. Second-tier steroid profiling obviated repeat screens of borderline results (355 per year average). CONCLUSIONS In comparing the 2 screening protocols, the FPR of CAH NBS remains high, the PPV remains low, and false-negatives occur more frequently than has been reported. Physicians should be cautioned that a negative NBS does not necessarily rule out classic CAH; therefore, any patient for whom there is clinical concern for CAH should receive immediate diagnostic testing.
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Affiliation(s)
- Kyriakie Sarafoglou
- Division of Endocrinology, Department of Pediatrics, University of Minnesota Amplatz Children’s Hospital, Minneapolis, Minnesota 55454, USA.
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Ryckman KK, Berberich SL, Shchelochkov OA, Cook DE, Murray JC. Clinical and environmental influences on metabolic biomarkers collected for newborn screening. Clin Biochem 2012; 46:133-8. [PMID: 23010448 DOI: 10.1016/j.clinbiochem.2012.09.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 09/11/2012] [Accepted: 09/13/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Identifying common clinical and environmental factors that influence newborn metabolic biomarkers will improve the utilization of metabolite panels for clinical diagnostic medicine. DESIGN AND METHODS Environmental effects including gender, season of birth, gestational age, birth weight, feeding method and age at time of collection were evaluated for over 50 metabolites collected by the Iowa Neonatal Metabolic Screening Program on 221,788 newborns over a six year period. RESULTS We replicated well known observations that low birth weight and preterm infants have higher essential amino acids and lower medium and long chain acylcarnitine levels than their term counterparts. Smaller, but still significant, differences were observed for gender and timing of sample collection, specifically the season in which the infant was born. Most intriguing were our findings of higher thyroid stimulating hormone in the winter months (P<1×10(-40)) which correlated with an increased false positive rate of congenital hypothyroidism in the winter (0.9%) compared to summer (0.6%). Previous studies, conducted globally, have identified an increased prevalence of suspected and confirmed cases of congenital hypothyroidism in the winter months. We found that the percentage of unresolved suspected cases were slightly higher in the winter (0.3% vs. 0.2%). CONCLUSIONS We identified differences in metabolites by gestational age, birth weight, gender and season. Some are widely reported such as gestational age and birth weight, while others such as the effect of seasonality are not as well studied.
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Affiliation(s)
- Kelli K Ryckman
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
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Reverse-hybridization assay for rapid detection of common CYP21A2 mutations in dried blood spots from newborns with elevated 17-OH progesterone. Clin Chim Acta 2012; 414:211-4. [PMID: 22985688 DOI: 10.1016/j.cca.2012.09.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 09/09/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder most commonly caused by defects in the CYP21A2 gene. Neonatal CAH-screening based on 17-hydroxyprogesterone (17-OHP) measurements prevents life-threatening salt wasting conditions in newborns, but results in a considerable false-positive rate. Therefore, efficient second tier tests are required. METHODS We developed a reverse-hybridization test strip-based assay (CAH StripAssay) covering the most prevalent CYP21A2 point mutations/small insertions/deletions occurring in Middle European populations. Assay specificity was validated using plasmid clones, and wild-type and mutant reference DNAs. Its practicability was evaluated in 271 samples from patients with CAH, suspected CAH, and dried blood spots from screening-positive newborns. RESULTS All eleven point mutations and 51% of large deletions/conversions could be unambiguously identified when compared to reference methods (DNA sequencing, MLPA). After exclusion of rare mutations (6.4%) not covered by the StripAssay, the overall detection rate was 85%. Undetected heterozygous deletions/conversions caused a lack of information, but did not result in an incorrect prediction of phenotypes. CONCLUSIONS Our novel CAH StripAssay proved to be a fast (7h) and reliable method for detection of common CYP21A2 mutations. Implemented as a second-tier test in CAH newborn screening, it has the potential to significantly reduce recall rates.
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Botelho Barra C, Novato Silva I, Leite Pezzuti I, Nélio Januário J. Neonatal screening for congenital adrenal hyperplasia. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1016/s0104-4230(12)70229-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Barra CB, Silva IN, Pezzuti IL, Januário JN. Triagem neonatal para hiperplasia adrenal congênita. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1590/s0104-42302012000400017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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An automated method on analysis of blood steroids using liquid chromatography tandem mass spectrometry: Application to population screening for congenital adrenal hyperplasia in newborns. Clin Chim Acta 2011; 412:2076-84. [DOI: 10.1016/j.cca.2011.07.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 07/12/2011] [Accepted: 07/15/2011] [Indexed: 11/21/2022]
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Hayashi G, Faure C, Brondi MF, Vallejos C, Soares D, Oliveira É, Brito VN, Mendonca BB, Bachega TASS. Weight-adjusted neonatal 17OH-progesterone cutoff levels improve the efficiency of newborn screening for congenital adrenal hyperplasia. ACTA ACUST UNITED AC 2011; 55:632-7. [DOI: 10.1590/s0004-27302011000800019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 10/16/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE: To evaluate weight-adjusted strategy for levels of neonatal-17OHP in order to improve newborn screening (NBS) efficiency. SUBJECTS AND METHODS: Blood samples collected between 2-7 days of age from 67,640 newborns were evaluated. When N17OHP levels were > 20 ng/mL, and a second sample was requested. We retrospectively analyzed neonatal-17OHP levels measured by Auto DELFIA- B024-112 assay, grouped according to birth-weight: G1: < 1,500 g, G2: 1,501-2,000 g, G3: 2,000-2,500 g and G4: > 2,500 g. 17OHP cutoff values were determined for each group using the 97.5th, 99th, 99.5th and 99.8th percentiles. RESULTS: 0.5% of newborns presented false-positive results using the cutoff level > 20 ng/mL for all groups. Neonates of low birthweight made up 69% of this group. Seven full-term newborns presented congenital adrenal hyperplasia (CAH) and, except for one of them, 17OHP levels were > 120 ng/mL. Only the 99.8th percentile presented higher predictive positive value (2%), and lower rate of false-positives in all groups. CONCLUSIONS: We suggest the use of 99.8th percentile obtained by weight-adjusted N17OHP values of healthy newborns to reduce the rate of false-positive results in NBS.
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Affiliation(s)
- Giselle Hayashi
- Associação de Pais e Amigos dos Excepcionais de São Paulo, Brazil; Universidade de São Paulo, Brazil
| | - Cláudia Faure
- Associação de Pais e Amigos dos Excepcionais de São Paulo, Brazil
| | | | - Carla Vallejos
- Associação de Pais e Amigos dos Excepcionais de São Paulo, Brazil
| | - Daiana Soares
- Associação de Pais e Amigos dos Excepcionais de São Paulo, Brazil
| | - Érica Oliveira
- Associação de Pais e Amigos dos Excepcionais de São Paulo, Brazil
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Abstract
PURPOSE OF REVIEW Congenital adrenal hyperplasia (CAH) in children, the majority of which is due to 21-hydroxylase deficiency, represents a group of disorders in which there is impaired cortisol synthesis and abnormalities in adrenal hormonal profiles. There continues to be debate regarding the optimal management of and treatment for these children. This review will highlight the most recent advances in neonatal screening for CAH, as well as the timeliest recommendations for the treatment and management of 21-hydroxylase deficiency, both the classic and nonclassic forms of the disorder. RECENT FINDINGS Substantive advancements have been made with regard to neonatal screening for CAH, allowing for earlier diagnosis, while minimizing the morbidity and mortality associated with delayed detection. Although the achievement of normal growth and development remains the ultimate goal of treatment, recent studies have provided further insight into the management and refinement of therapy in these children. SUMMARY The optimal management and treatment for children with CAH is still unclear. Although there have been recent advances in the diagnosis and treatment of this group of disorders, there is still much to learn in order to optimize therapy for these individuals.
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Affiliation(s)
- Christine M. Trapp
- Division of Pediatric Endocrinology, Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032
| | - Phyllis W. Speiser
- Division of Pediatric Endocrinology, Cohen Children’s Medical Center of New York, Hofstra University School of Medicine, New Hyde Park, New York 11040
| | - Sharon E. Oberfield
- Division of Pediatric Endocrinology, Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032
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Rossi C, Calton L, Brown HA, Gillingwater S, Wallace AM, Petrucci F, Ciavardelli D, Urbani A, Sacchetta P, Morris M. Confirmation of congenital adrenal hyperplasia by adrenal steroid profiling of filter paper dried blood samples using ultra-performance liquid chromatography-tandem mass spectrometry. Clin Chem Lab Med 2011; 49:677-84. [PMID: 21288182 DOI: 10.1515/cclm.2011.109] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The specificity of screening for congenital adrenal hyperplasia by direct measurement of 17-hydroxyprogesterone in filter paper dried blood spot samples by immunoassay is low and has a high false-positive rate. In order to reduce the false-positive rate of this test, we developed a rapid, robust, specific confirmatory procedure in which cortisol, 4-androstene-3,17-dione and 17-hydroxyprogesterone were measured simultaneously by ultra-performance liquid chromatography-tandem mass spectrometry. METHODS After extraction, samples were analysed by ultra-performance liquid chromatography-tandem mass spectrometry and 17-hydroxyprogesterone was quantified accurately. Other steroids were determined using stable deuterated internal standards. In total, 25 patient blood spot samples and 92 control samples were analysed. RESULTS The assay was linear for 17-hydroxyprogesterone, with a coefficient of determination >0.997 and imprecision ≤ 6.5%. An upper limit of normal for 17-hydroxyprogester-one of 4.45 nmol/L was established by analysing a cohort of samples from unaffected newborns. In addition, a cut-off of 3.5 for the peak areas ratio (17-hydroxyprogesterone+4-androstene-3,17-dione)/cortisol, allows confirmation of the affected steroidogenic enzyme. CONCLUSIONS A high throughput method for the detection of steroids related to congenital adrenal hyperplasia has been developed, allowing the false-positive rate associated with screening for 17-hydroxyprogesterone by immunoassay to be determined.
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Affiliation(s)
- Claudia Rossi
- Centre of Study on Aging (CeSI), G. d'Annunzio University Foundation, Chieti, Italy.
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Fernández BH, Fernández ME, Íñiguez ED, Zubicaray BE, Martín MBR, Arnao MDR, Sánchez AR. Neonatal screening for congenital adrenal hyperplasia: transitory elevation of 17-hydroxyprogesterone. ACTA ACUST UNITED AC 2011. [DOI: 10.1515/jpem.2011.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Marchini GS, Cocuzza M, Pagani R, Torricelli FC, Hallak J, Srougi M. Testicular adrenal rest tumor in infertile man with congenital adrenal hyperplasia: case report and literature review. SAO PAULO MED J 2011; 129:346-51. [PMID: 22069134 PMCID: PMC10868949 DOI: 10.1590/s1516-31802011000500010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 08/03/2010] [Accepted: 03/16/2011] [Indexed: 11/22/2022] Open
Abstract
CONTEXT Synthesis of cortisol and aldosterone is impaired in patients with congenital adrenal hyperplasia (CAH) because of 21-hydroxylase deficiency. Men with CAH have low fertility rates compared with the normal population, and this is related to testicular adrenal rest tumors. Findings of azoospermia in combination with a testicular tumor on ultrasound are likely to have a mechanical cause, especially when in the testicular mediastinum. The preferred treatment method consists of intensive corticoid therapy. However, when the tumor is unresponsive to steroid therapy, surgical treatment should be considered. CASE REPORT We present the case of a male patient with CAH due to 21-hydroxylase deficiency who presented a testicular tumor and azoospermia. Treatment with low daily corticoid doses had previously been started by an endocrinologist, but after 12 months, no significant change in sperm count was found. Although the adrenocorticotrophic hormone and 17-hydroxyprogesterone levels returned to normal values, the follicle-stimulating hormone (FSH), luteinizing hormone and testosterone levels remained unchanged. Ultrasound examination confirmed that the testicles were small and heterogenous bilaterally, and revealed a mosaic area at the projection of the testis network bilaterally. Magnetic resonance imaging confirmed the finding. Testicular biopsy revealed the presence of preserved spermatogenesis and spermiogenesis in 20% of the seminiferous tubules in the right testicle. The patient underwent testis-sparing tumor resection. After 12 months of follow-up, there was no tumor recurrence but the patient still presented azoospermia and joined an intracytoplasmic sperm injection program.
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Affiliation(s)
- Giovanni Scala Marchini
- Department of Urology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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Slaughter JL, Meinzen-Derr J, Rose SR, Leslie ND, Chandrasekar R, Linard SM, Akinbi HT. The effects of gestational age and birth weight on false-positive newborn-screening rates. Pediatrics 2010; 126:910-6. [PMID: 20974783 DOI: 10.1542/peds.2010-0943] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Newborn-screening false-positive rates (FPRs) are disproportionately increased in preterm infants. The objective of this study was to determine variation in newborn screening FPRs according to birth weight and gestational age. Our secondary objective was to examine the effect of postnatal age on FPRs in preterm infants. METHODS The Ohio State Newborn Screening Program Database was analyzed to determine the overall and birth weight-specific FPRs for 18 analytes. Data were stratified into birth weight categories (<1000 g, 1000-1499 g, 1500-2499 g, 2500-3999 g, and >4000 g). In addition, to examine the effect of postnatal age on FPRs, we examined the 2 analytes with the highest FPRs, thyrotropin with back-up thyroxine and 17-hydroxyprogesterone, in infants whose gestational age was <32 weeks, determined on the basis of postnatal age at screening. RESULTS Data from 448 766 neonates were reviewed. Infants with very low birth weight (VLBW) comprised 1.9% of the study cohort, but accounted for 18% of false-positive results. For 14 of 18 analytes studied, FPRs increased with decreasing birth weight/gestational age and were significantly increased in infants with VLBW compared with infants who weighed 2500 to 3999 g (P < .001). Thyrotropin/back-up thyroxine and 17-hydroxyprogesterone accounted for 62% of total false-positive results in VLBW infants. When blood specimens were collected at a postnatal age of ≥ 48 hours in infants born at <32 weeks, a 44% relative reduction in 17-hydroxyprogesterone false-positive results was detected. CONCLUSIONS False-positive newborn-screening rates are disproportionately increased in VLBW infants. FPRs may be reduced by delaying screening of <32 weeks' gestation, preterm infants until 24 to 48 hours' postnatal age.
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Affiliation(s)
- Jonathan L Slaughter
- Cincinnati Children's Hospital Medical Center, Division of Neonatology, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH 45229-3039, USA
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Speiser PW, Azziz R, Baskin LS, Ghizzoni L, Hensle TW, Merke DP, Meyer-Bahlburg HFL, Miller WL, Montori VM, Oberfield SE, Ritzen M, White PC. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010; 95:4133-60. [PMID: 20823466 PMCID: PMC2936060 DOI: 10.1210/jc.2009-2631] [Citation(s) in RCA: 646] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We developed clinical practice guidelines for congenital adrenal hyperplasia (CAH). PARTICIPANTS The Task Force included a chair, selected by The Endocrine Society Clinical Guidelines Subcommittee (CGS), ten additional clinicians experienced in treating CAH, a methodologist, and a medical writer. Additional experts were also consulted. The authors received no corporate funding or remuneration. CONSENSUS PROCESS Consensus was guided by systematic reviews of evidence and discussions. The guidelines were reviewed and approved sequentially by The Endocrine Society's CGS and Clinical Affairs Core Committee, members responding to a web posting, and The Endocrine Society Council. At each stage, the Task Force incorporated changes in response to written comments. CONCLUSIONS We recommend universal newborn screening for severe steroid 21-hydroxylase deficiency followed by confirmatory tests. We recommend that prenatal treatment of CAH continue to be regarded as experimental. The diagnosis rests on clinical and hormonal data; genotyping is reserved for equivocal cases and genetic counseling. Glucocorticoid dosage should be minimized to avoid iatrogenic Cushing's syndrome. Mineralocorticoids and, in infants, supplemental sodium are recommended in classic CAH patients. We recommend against the routine use of experimental therapies to promote growth and delay puberty; we suggest patients avoid adrenalectomy. Surgical guidelines emphasize early single-stage genital repair for severely virilized girls, performed by experienced surgeons. Clinicians should consider patients' quality of life, consulting mental health professionals as appropriate. At the transition to adulthood, we recommend monitoring for potential complications of CAH. Finally, we recommend judicious use of medication during pregnancy and in symptomatic patients with nonclassic CAH.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children's Medical Center of New York and Hofstra University School of Medicine, New Hyde Park, New York 11040, USA
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De Jesús VR, Simms DA, Schiffer J, Kennedy M, Mei JV, Hannon WH. Pilot proficiency testing study for second tier congenital adrenal hyperplasia newborn screening. Clin Chim Acta 2010; 411:1684-7. [PMID: 20619255 DOI: 10.1016/j.cca.2010.06.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 05/27/2010] [Accepted: 06/30/2010] [Indexed: 12/01/2022]
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) is caused by inherited defects in steroid biosynthesis. The Newborn Screening Quality Assurance Program (NSQAP) initiated a pilot, dried-blood spot (DBS)-based proficiency testing program designed to investigate materials and laboratory performance for second tier CAH screening by tandem mass spectrometry (MS/MS). METHODS The ratio of 17-α-hydroxyprogesterone (17-OHP), androstenedione (4-AD) and cortisol is used as an indicator of CAH in laboratory protocols for second tier analysis of DBS specimens. DBS prepared by NSQAP contained a range of steroid concentrations resulting in different clinical ratios. Laboratories received blind-coded DBS specimens and reported results to NSQAP for evaluation. RESULTS Quantitative values reported by participants for 17-OHP, 4-AD, and cortisol, reflected small differences in their analytical methods. Average quantitative values for 17-OHP increased from 81% to 107% recovery over the 3.5-year period; cortisol recoveries increased from 61.9% to 89.5%; and 4-AD recoveries decreased from 184% to 68%. CONCLUSIONS Laboratory participation in the CAH second tier proficiency testing program has resulted in improved analyte recoveries and enhanced sample preparation methodologies. NSQAP services for the second tier CAH analysis in DBS demonstrate the need for surveillance to ensure harmonization and continuous improvements, and to achieve sustained high-performance of newborn screening laboratories worldwide.
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Affiliation(s)
- Víctor R De Jesús
- Newborn Screening Quality Assurance Program, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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