Adult height in congenital hypothyroidism: prognostic factors and the importance of compliance with treatment

Pubertal development and adult height in patients with congenital hypothyroidism detected by neonatal screening in southern Brazil

Objectives Adequate treatment of congenital hypothyroidism (CH) is required for normal growth and sexual development. To evaluate pubertal development in patients with permanent CH detected by a statewide Neonatal Screening Program of Paraná and, secondly, to evaluate adult height (AH) in a subgroup of patients. Methods Clinical, laboratory, and auxological data obtained from medical records of 174 patients (123 girls). Results Median chronological age (CA) at treatment initiation was 24 days, and mean initial levothyroxine dose was 11.7 ± 1.9 μg/kg/day; mean CA at puberty onset was 11.5 ± 1.3 years (boys) and 9.7 ± 1.2 years (girls); mean CA in girls who underwent menarche (n=81) was 12.1 ± 1.1 years. Thyroid-stimulating hormone (TSH) values above the normal range were observed in 36.4% of the boys and 32.7% of the girls on puberty onset, and in 44.6% around menarche. Among 15 boys and 66 girls who had reached the AH, the median height z-score value was significantly greater than the target height (TH) z-score value in boys (p=0.01) and in girls (p<0.001). Boys with normal TSH values at puberty onset had greater mean AH z-score compared with boys with TSH values above the normal range (p=0.04). Conclusions In this group, pubertal development in girls with CH was not different from that reported in healthy girls in the general Brazilian population. Boys with higher TSH at puberty onset may have an increased risk of not reaching their potential height compared with those with normal TSH during this period. In a subgroup who attained AH, the median AH z-score was greater than the median TH z-score.

A new way to estimate neurologic disease prevalence in the United States: Illustrated with MS

OBJECTIVE

Considerable gaps exist in knowledge regarding the prevalence of neurologic diseases, such as multiple sclerosis (MS), in the United States. Therefore, the MS Prevalence Working Group sought to review and evaluate alternative methods for obtaining a scientifically valid estimate of national MS prevalence in the current health care era.

METHODS

We carried out a strengths, weaknesses, opportunities, and threats (SWOT) analysis for 3 approaches to estimate MS prevalence: population-based MS registries, national probability health surveys, and analysis of administrative health claims databases. We reviewed MS prevalence studies conducted in the United States and critically examined possible methods for estimating national MS prevalence.

RESULTS

We developed a new 4-step approach for estimating MS prevalence in the United States. First, identify administrative health claim databases covering publicly and privately insured populations in the United States. Second, develop and validate a highly accurate MS case-finding algorithm that can be standardly applied in all databases. Third, apply a case definition algorithm to estimate MS prevalence in each population. Fourth, combine MS prevalence estimates into a single estimate of US prevalence, weighted according to the number of insured persons in each health insurance segment.

CONCLUSIONS

By addressing methodologic challenges and proposing a new approach for measuring the prevalence of MS in the United States, we hope that our work will benefit scientists who study neurologic and other chronic conditions for which national prevalence estimates do not exist.

The prevalence of MS in the United States: A population-based estimate using health claims data

OBJECTIVE

To generate a national multiple sclerosis (MS) prevalence estimate for the United States by applying a validated algorithm to multiple administrative health claims (AHC) datasets.

METHODS

A validated algorithm was applied to private, military, and public AHC datasets to identify adult cases of MS between 2008 and 2010. In each dataset, we determined the 3-year cumulative prevalence overall and stratified by age, sex, and census region. We applied insurance-specific and stratum-specific estimates to the 2010 US Census data and pooled the findings to calculate the 2010 prevalence of MS in the United States cumulated over 3 years. We also estimated the 2010 prevalence cumulated over 10 years using 2 models and extrapolated our estimate to 2017.

RESULTS

The estimated 2010 prevalence of MS in the US adult population cumulated over 10 years was 309.2 per 100,000 (95% confidence interval [CI] 308.1-310.1), representing 727,344 cases. During the same time period, the MS prevalence was 450.1 per 100,000 (95% CI 448.1-451.6) for women and 159.7 (95% CI 158.7-160.6) for men (female:male ratio 2.8). The estimated 2010 prevalence of MS was highest in the 55- to 64-year age group. A US north-south decreasing prevalence gradient was identified. The estimated MS prevalence is also presented for 2017.

CONCLUSION

The estimated US national MS prevalence for 2010 is the highest reported to date and provides evidence that the north-south gradient persists. Our rigorous algorithm-based approach to estimating prevalence is efficient and has the potential to be used for other chronic neurologic conditions.

Final height of Korean patients with early treated congenital hypothyroidism

Purpose

Congenital hypothyroidism (CH) is the most common endocrine disorder in children. Thyroid hormone deprivation results not only in mental retardation but also growth retardation. This study investigates the final height (FH) in Korean patients with CH detected by newborn screening and examines factors that may affect the FH.

Methods

The medical records of Korean CH patients (n=45) were reviewed. The FH was examined and target height (TH) was calculated based on mid-parental height. The FH z score (FHZ) and TH z score (THZ) were computed using the 2007 Korean National Growth Chart. The FHZ and THZ were compared with a Student t test. The impact of the etiology of CH (athyreosis, dyshormonogenesis, ectopic thyoid, hypoplastic thyroid), initial serum thyroid stimulating hormone (TSH) level, initial free thyroxine (T4) level, and time of therapy initiation based on FH was assessed.

Results

The mean FHZ was 0.10±1.01 for male patients and -0.11±1.09 for female patients. There were no significant differences between FHZ and THZ for both female (P=0.356) and male patients (P=0.237). No significant relationship was found between FH and the etiology of CH, initial TSH level, initial free T4 level, and the time of therapy initiation.

Conclusion

Early intervention and satisfactory management do not appear to impede growth in Korean patients with CH. Thus, early detection and proper management of patients with CH detected by newborn screening program are necessary.

Growth development in children with congenital hypothyroidism: the effect of screening and treatment variables-a comprehensive longitudinal study

Investigating the screening and early treatment factors potentially affects the growth status of the patients with congenital hypothyroidism. In a longitudinal study, 760 (45 % girl) neonates born in 2002-2009 with congenital hypothyroidism diagnosed by neonatal screening in Isfahan-Iran were followed up to 5 years from the time of diagnosis (i.e., 3-4 records for the first year of age and 2-3 records after that). During follow-up, height, weight, and head circumferences of the patients were measured. Diagnostic and therapeutic factors included serum thyroxine and thyroid stimulating hormone concentration at diagnosis and after treatment initiation, the age at onset of treatment, the first therapeutic dosage, and age at first normalization of thyroxine and thyroid stimulating hormone. Quantile regression for longitudinal data was used for determining the effects of main factors on growth development. Longitudinal growth in height and weight was significantly correlated with the age at onset of treatment and the first therapeutic dosage (p < 0.01), while head circumference only with first therapeutic dosage (p < 0.05). Growth in weight and head circumference was affected by thyroid stimulating hormone at the time of diagnosis (p < 0.05). Also the age of thyroxine normalization had heterogeneous significant impact over the proposed quantiles on weight (p < 0.05), height (p < 0.01), and head circumference (p < 0.001). Among studied factors, the first therapeutic dosage, age at onset of treatment and age of thyroxine normalization seem to be more important for anthropometric development, suggesting that more optimal outcome might be achievable through earlier treatment and appropriate levothyroxine dosage.

Summary of comprehensive systematic review: Rehabilitation in multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

OBJECTIVE

To systematically review the evidence regarding rehabilitation treatments in multiple sclerosis (MS).

METHODS

We systematically searched the literature (1970-2013) and classified articles using 2004 American Academy of Neurology criteria.

RESULTS

This systematic review highlights the paucity of well-designed studies, which are needed to evaluate the available MS rehabilitative therapies. Weekly home/outpatient physical therapy (8 weeks) probably is effective for improving balance, disability, and gait (MS type unspecified, participants able to walk ≥5 meters) but probably is ineffective for improving upper extremity dexterity (1 Class I). Inpatient exercises (3 weeks) followed by home exercises (15 weeks) possibly are effective for improving disability (relapsing-remitting MS [RRMS], primary progressive MS [PPMS], secondary progressive MS [SPMS], Expanded Disability Status Scale [EDSS] 3.0-6.5) (1 Class II). Six weeks' worth of comprehensive multidisciplinary outpatient rehabilitation possibly is effective for improving disability/function (PPMS, SPMS, EDSS 4.0-8.0) (1 Class II). Motor and sensory balance training or motor balance training (3 weeks) possibly is effective for improving static and dynamic balance, and motor balance training (3 weeks) possibly is effective for improving static balance (RRMS, SPMS, PPMS) (1 Class II). Breathing-enhanced upper extremity exercises (6 weeks) possibly are effective for improving timed gait and forced expiratory volume in 1 second (RRMS, SPMS, PPMS, mean EDSS 4.5); this change is of unclear clinical significance. This technique possibly is ineffective for improving disability (1 Class II). Inspiratory muscle training (10 weeks) possibly improves maximal inspiratory pressure (RRMS, SPMS, PPMS, EDSS 2-6.5) (1 Class II).

Multiple sclerosis prevalence in the United States commercially insured population

OBJECTIVE

To estimate the US commercially insured multiple sclerosis (MS) annual prevalence from 2008 to 2012.

METHODS

The study was a retrospective analysis using PharMetrics Plus, a nationwide claims database for over 42 million covered US representative lives. Annual point prevalence required insurance eligibility during an entire year. Our primary annual MS identification algorithm required 2 inpatient claims coded ICD-9 340 or 3 outpatient claims coded ICD-9 340 or 1 MS-indicated disease-modifying therapy claim. Age-adjusted annual prevalence estimates were extrapolated to the US population using US Census data.

RESULTS

The 2012 MS prevalence was 149.2 per 100,000 individuals (95% confidence interval 147.6-150.9). Prevalence was consistent over 2008-2012. Female participants were 3.13 times more likely to have MS. The highest prevalence was in participants aged 45-49 years (303.5 per 100,000 individuals [295.6-311.5]). The East Census region recorded the highest prevalence (192.1 [188.2-196.0]); the West Census region recorded the lowest prevalence (110.7 [105.5-116.0]). The US annual 2012 MS extrapolated population was 403,630 (387,445-419,833).

CONCLUSIONS

MS prevalence rates from a representative commercially insured database were higher than or consistent with prior US estimates. For further accuracy improvement of US prevalence estimates, results should be confirmed after validation of MS identification algorithms, and should be expanded to other US populations, including the government-insured and the uninsured.

Final height in Italian patients with congenital hypothyroidism detected by neonatal screening: a 20-year observational study

BACKGROUND

Linear growth and final height are reported as normal in congenital hypothyroid patients in the neonatal screening era.

METHODS

We evaluated the final height in 215 patients with congenital hypothyroidism to assess if it improved over the last 2 decades.

RESULTS

Final height (-0.1 ± 1.0 SDS) was higher than target height (-0.8 ± 1.0 SDS, p < 0.001) and not different among the 4 quartiles for birthdate. It was correlated with target height (r(2) = 0.564, p < 0.001) and height at puberty onset (r(2) = 0.685, p < 0.001), but not with age at diagnosis or the starting LT4/kg/day dose. The curve fitting analysis showed that the age at diagnosis progressively decreased during the 20-year study period, while the target height and the starting LT4/kg/day increased. Final height was not affected by the birthdate, the age at diagnosis, the starting LT4 dose.

CONCLUSIONS

The final height is higher than the target height, but despite the improvement in the screening and the treatment, it did not improve over the last 20 years. These findings are in keeping with the described secular trend and suggest that earlier diagnosis and replacement therapy do not significantly modify final height in these patients.

Gestational hypothyroidism increases the severity of experimental autoimmune encephalomyelitis in adult offspring

BACKGROUND

Maternal thyroid hormones play a fundamental role in appropriate fetal development during gestation. Offspring that have been gestated under maternal hypothyroidism suffer cognitive impairment. Thyroid hormone deficiency during gestation can significantly impact the central nervous system by altering the migration, differentiation, and function of neurons, oligodendrocytes, and astrocytes. Given that gestational hypothyroidism alters the immune cell ratio in offspring, it is possible that this condition could result in higher sensitivity for the development of autoimmune diseases.

METHODS

Adult mice gestated under hypothyroidism were induced with experimental autoimmune encephalomyelitis (EAE). Twenty-one days after EAE induction, the disease score, myelin content, immune cell infiltration, and oligodendrocyte death were evaluated.

RESULTS

We observed that mice gestated under hypothyroidism showed higher EAE scores after disease induction during adulthood compared to mice gestated in euthyroidism. In addition, spinal cord sections of mice gestated under hypothyroidism that suffered EAE in adulthood showed higher demyelination, CD4(+) and CD8(+) infiltration, and increased oligodendrocyte death.

CONCLUSIONS

These results show for the first time that a deficiency in maternal thyroid hormones during gestation can influence the outcome of a central nervous system inflammatory disease, such as EAE, in their offspring. These data strongly support evaluating thyroid hormones in pregnant women and treating hypothyroidism during pregnancy to prevent increased susceptibility to inflammatory diseases in the central nervous system of offspring.

Growth and specialized growth charts of children with congenital hypothyroidism detected by neonatal screening in isfahan, iran

Objectives. The aim of the current study was to investigate the growth status of CH, generate specialized growth charts of CH infants, and compare them with their counterparts of regional normal infants. Methods. In this prospective cohort study, 760 (345 girls and 415 boys) neonates born in 2002-2009 diagnosed by neonatal CH screening program in Isfahan were followed up from the time of diagnosis. 552 healthy children were recruited as a control group. The empirical 3rd, 15th, 50th, 85th, and 97th percentiles for height, weight, and head circumference of both sexes were determined and compared with their counterpart values of the control group. The relative frequency of patients with impaired growth for each studied variable was determined. Also, specialized growth charts of CH patients were generated. Results. The percentiles of weight, height, and head circumference of studied patients are significantly different from regional healthy children (P < 0.001). The relative frequency of impaired head circumference was decreased to less than 3% at the 3rd year of age and for height it reached gradually 3% and 9% at the 5th year of age for boys and girls, respectively (P < 0.05); however for weight still it was statistically more than 3% in both sexes. Conclusion. CH patients had impaired growth development which was improved during follow up, but the catch-up time was earlier for head circumference and later for weight.

Effect of Prolonged Discontinuation of L-Thyroxine Replacement in a Child with Congenital Hypothyroidism

When diagnosed through neonatal screening and treated promptly and adequately, infants with congenital hypothyroidism (CH) experience normal physical growth and neurological development. Here we present a 3-year-old boy diagnosed with CH as a newborn, who was subsequently left untreated and experienced significant growth failure and developmental delay. This case emphasizes the importance of a consistent adherence to treatment in preventing such complications, especially in infancy and early childhood.

[Growth and maturation in the patients with congenital hypothyroidism detected by the neonatal screening program in Catalonia, Spain (1986-1997)]

BACKGROUND AND OBJECTIVE

Many countries have developed screening programs for CH that bring about a normal somatic and psychological development. The aim of this study is to evaluate the evolution of cases detected by the screening program of congenital hypothyroidism in Catalonia.

PATIENTS AND METHODS

The was a descriptive, longitudinal study of a series of 136 cases of congenital hypothyroidism detected by the screening program in Catalonia from 1986 to 1997 and who had been checked in the Maternal-infantile Vall d'Hebron Hospital in Barcelona. Follow-up was carried out for growth and a psychological exploration was performed (McCarthy test and WISC-R).

RESULTS

Males (30 cases, 22.1%) and females (106 cases, 77.9%) with congenital hypothyroidism of this study had a height, weight and BMI that were not different from those of the current population of Barcelona. Height was 0.5 SD above the Tanner reference values of 1966 and BMI was one SD above the Roland-Cachera reference values of 1982. This secular acceleration of growth has been observed in all developed countries. In a sample of 37.5% of the cases, psychological development did not differ from that of the reference population. However, a greater intensity of neonatal hypothyroidism and its most delayed normalization correlated negatively with the score in the psychological tests.

CONCLUSIONS

Once normalization of growth and psychological development are achieved, the screening program of congenital hypothyroidism in Catalonia should be optimized by initiating treatment as soon as possible to avoid the possibility that some children do not reach their complete intellectual potential.

Estrogen controls vitamin D3-mediated resistance to experimental autoimmune encephalomyelitis by controlling vitamin D3 metabolism and receptor expression

Multiple sclerosis (MS) is an autoimmune, neurodegenerative disease with a rapidly increasing female gender bias. MS prevalence decreases with increasing sunlight exposure, supporting our hypothesis that the sunlight-dependent hormone 1,25-dihydroxyvitamin D(3) (1,25-(OH)(2)D(3)) is a natural inhibitor of autoimmune T cell responses in MS. We found that vitamin D(3) inhibited experimental autoimmune encephalomyelitis (EAE) in intact female mice, but not in ovariectomized females or males. To learn whether 17beta-estradiol (E(2)) is essential for vitamin D(3)-mediated protection, ovariectomized female mice were given E(2) or placebo and evaluated for vitamin D(3)-mediated EAE resistance. Diestrus-level E(2) implants alone provided no benefit, but they restored vitamin D(3)-mediated EAE resistance in the ovariectomized females. Synergy between E(2) and vitamin D(3) occurred through vitamin D(3)-mediated enhancement of E(2) synthesis, as well as E(2)-mediated enhancement of vitamin D receptor expression in the inflamed CNS. In males, E(2) implants did not enable vitamin D(3) to inhibit EAE. The finding that vitamin D(3)-mediated protection in EAE is female-specific and E(2)-dependent suggests that declining vitamin D(3) supplies due to sun avoidance might be contributing to the rapidly increasing female gender bias in MS. Moreover, declining E(2) synthesis and vitamin D(3)-mediated protection with increasing age might be contributing to MS disease progression in older women.

Case-Finding for MS Prevalence Studies in Small Communities Requires a Community-Based Approach

In response to citizen concerns in 5 small Illinois towns, community-based case-finding determined the prevalence of multiple sclerosis (MS). Potential cases were identified through town meetings, publicity, advocacy groups and local volunteer outreach coordinators. Estimated prevalence based on available medical records for self-identifying individuals for 3 of the 5 communities was high (218-231 per 100,000 population) compared to other studies. Scanning databases in medical offices used in many other studies may miss MS cases; yet tracking medical records is labor-intensive and sometimes restricted by privacy guidelines. MS registries could improve case-finding accuracy and efficiency.

Growth of patients with congenital hypothyroidism detected by neonatal screening in Japan

BACKGROUND

The growth of patients with congenital hypothyroidism detected by neonatal screening in Japan was investigated. The data investigated were obtained from Medical Aid Program for Chronic Pediatric Diseases of Specified Categories registered in 2002.

METHOD

The present study included 2341 patients (1030 male, 1311 female) registered as having congenital hypothyroidism. To investigate the growth of these patients, their heights plotted on cross-sectional growth charts for boys and girls, their bodyweights expressed as percentage of bodyweight for height and the frequency distribution of percentage of bodyweight for height were assessed.

RESULTS

Cross-sectional growth charts of both male and female patients showed that the heights of the majority of the patients with congenital hypothyroidism were within +/-2SD. Approximately half of the patients with heights below -2SD, had some complications. The mean percentages of ideal bodyweights for height were 103.0 +/- 12.9% for both sexes (+/-SD, n = 2033), 103.3 +/- 12.7% for boys, and 102.7 +/- 12.9% for girls. The frequency distribution of percentage of bodyweight showed no tendency of shifting to either ends in comparison with normal distribution curve.

CONCLUSION

Patients with congenital hypothyroidism detected by neonatal screening had normal growth in general, suggesting that the neonatal screening system is being performed efficiently from detection to treatment of the disease in Japan. However, it remains unclear whether some uncomplicated patients with a height below -2 SD are sufficiently treated or not. Close observation of these patients may be needed.

Longitudinal Assessment of Levo-Thyroxine Therapy for Congenital Hypothyroidism: Relationship with Aetiology, Bone Maturation and Biochemical Features

AIMS

To evaluate therapy and dose adjustments in patients with congenital hypothyroidism (CH), longitudinally followed up until 16 years old, according to aetiology, Beclard's nuclei presence, and thyroxine (T4) level at diagnosis.

METHODS

L-T4/kg/day and dose change ratio (CR) were assessed in 74 CH patients.

RESULTS

The dose was statistically larger in athyreosis than in dyshormonogenesis (1-10 and beyond 14 years) and in ectopy (2, 15, 16 years). The ectopic children required statistically larger L-T4/kg than the dyshormonogenetic ones (3-7 years). The L-T4/kg/day was increased, not statistically, in patients or with T4 <30 nmol/l or without Beclard's nuclei at diagnosis. The CR progressively dropped after the 6th month at each attendance, without any difference in terms of aetiology, T4 level at diagnosis, or Beclard's nuclei. The total CR was greater (significantly) in patients without Beclard's nuclei, and (not significantly) in those with T4 <30 nmol/l at diagnosis or with agenesia.

CONCLUSION

The L-T4 dose in CH is highly affected by the aetiology. The CR is higher in patients with delayed bone maturation at diagnosis. We suggest that these latter patients need blood tests more frequently to obtain a proper titration of the therapy.

Studies of multiple sclerosis in communities concerned about environmental exposures

Multiple sclerosis (MS) is an autoimmune disease that differentially affects women, people 30-60 years old, and Caucasians. Evidence indicates that it is a complex disease determined by both environmental factors and genetic susceptibility. People across the United States have expressed concern about perceived clusters of MS in their communities and the role of environmental exposures in the development of the disease. The Agency for Toxic Substances and Disease Registry (ATSDR) has funded several studies to address this issue, including a cluster investigation, several prevalence studies, and a case-control study. The cluster investigation illustrated that there are few data regarding the number of individuals with MS in the United States. Prevalence studies were conducted in Ohio, Missouri, and Texas to address this deficiency. The results support a regional difference in MS prevalence, although the reason for this difference is unclear. The results also underscore the need for additional epidemiological information about the distribution of MS in other areas of the United States and information on the underlying etiology of the disease. A case-control study is currently being conducted to examine potential risk factors for MS, including the role of environmental exposures and genetic susceptibility. Future research on MS should focus on large-scale studies and include collaboration among researchers with varied fields of expertise, such as epidemiology, neurology, and genetics.

A New Method to Determine Mean Adult Height from Incomplete Follow-Up Data

BACKGROUND/AIM

In long-term growth studies with adult height (AH) as outcome, reporting is often required while data are incomplete because some participants have not yet reached AH whereas others might be lost to follow-up. Current practice is to analyze only participants who did reach AH, which can easily give biased results. We introduce a new method into the area of growth research.

METHODS

We used the data of patients from a registration database and a growth study. The new method uses growth data in time intervals. The percentage of children still growing and the mean growth at each interval are used to determine mean AH.

RESULTS

With the new method, estimated mean AHs had smaller bias and standard error than with commonly used methods. The method is not hampered by a correlation between AH and age at reaching AH, unlike methods merely using patients who have reached AH.

CONCLUSION

In contrast to commonly used methods, the new method provides valid results on mean AH when complete actual measurements of AH are not (yet) available, provided that drop-out, if any, is not related to (disappointing) growth. As it also uses observed data of children with incomplete follow-up, the method employs the data more effectively.

Factors predicting final height in early treated congenital hypothyroid patients

OBJECTIVE

To evaluate pubertal development and final height (FH) in early treated patients with congenital hypothyroidism (CH) and to identify the main factors predicting FH.

DESIGN

Retrospective.

PATIENTS

Eighty-five patients with early diagnosed and treated CH.

MEASUREMENTS

Evaluation of length/height at diagnosis (mean age 26.6 days), at onset of puberty, and at the end of linear growth.

RESULTS

Mean FH was 161.7 cm in females and 173.8 cm in males, within +/- 0.9 cm of the 50th percentile of Italian growth charts, 5 cm higher than the mean target height (TH). Linear growth did not differ according to thyroid imaging findings. In males, height at onset of puberty was 0.16 standard deviation score (SDS), not statistically different from FH (-0.09 SDS). In females, height both at onset of puberty (0.39 SDS) and at menarche (0.57 SDS) was significantly higher (P < 0.001) than FH (-0.10 SDS). Puberty started at a mean chronological age of 10.2 and 11.6 years in females and males, respectively, with a corresponding bone age. FH correlated with TH and height at diagnosis, at onset of puberty, and at menarche. Multiple regression analysis showed that height at onset of puberty and TH are the most important factors explaining FH variability, although height at onset of puberty is slightly more important.

CONCLUSIONS

Our results, obtained in the largest reported available group of congenital hypothyroid patients, show that final height is higher than target height in both sexes and that height at onset of puberty is the main factor affecting final height.

Genetics, clinical management and natural history of congenital hypothyroidism

Congenital hypothyroidism has an incidence of 1:3000-4000 newborns. In the past, it was a common cause of mental retardation, although newborn screening has improved the prognosis. Several transcription factors are crucial to the early organogenesis of the thyroid, including TITF1, FOXE1, PAX8 and HHEX. Nevertheless, a small minority of humans with congenital hypothyroidism carry mutations in these genes. Long-term follow-up studies show that with appropriate therapy, the mental and physical development of congenital hypothyroidism patients is in the normal range, although somewhat delayed when compared with appropriate controls. Critical issues of treatment include early diagnosis and rapid correction of hypothyroidism by ensuring rapid initiation of treatment and rapid normalization of thyroid-stimulating hormone levels, especially in cases of severe congenital hypothyroidism. There has been recent question of the need to treat premature infants with hypothyroxinemia but no elevation of the thyroid-stimulating hormone concentration. Numerous controlled studies of the short- and long-term effects of thyroid hormone supplementation have not shown a consistent benefit in this group of patients. Future research will investigate further the genetic underpinnings of the condition. There is a worldwide need to prevent congenital hypothyroidism by ensuring adequate dietary iodine and to develop infrastructure to diagnose and treat congenital hypothyroidism in developing countries.

Infliximab in the treatment of rheumatoid arthritis

Rheumatoid arthritis is a chronic inflammatory systemic autoimmune disorder characterized by symmetric inflammation of synovial joints, leading to progressive erosion of cartilage and bone. Tumor necrosis factor-α antagonists have set a new therapeutic standard for rheumatoid arthritis. Tumor necrosis factor-α blocking agents, including infliximab, etanercept and adalimumab, have demonstrated substantial improvement in signs and symptoms, disability and quality of life, while significantly inhibiting joint damage in early and long-standing rheumatoid arthritis. The focus of this article will be the role of infliximab in the treatment of rheumatoid arthritis.

Multiple sclerosis mortality and patterns of comorbidity in the United States from 1990 to 2001

Multiple sclerosis (MS) is a neurodegenerative condition that can result in cognitive and physical disability and shortened life expectancy. However, population-based information is lacking regarding the mortality burden from MS in the United States. We investigated trends in MS mortality rates and examined important comorbidities in the United States from 1990 to 2001. MS deaths were matched by age, sex, and race/ethnicity with randomly selected deaths from other conditions for matched odds ratio comparisons. The overall age-adjusted mortality rate from MS was 1.44/100,000 population. MS mortality rates increased throughout the study period. MS mortality rates were higher in whites than in any other racial/ethnic group, followed by Blacks, Hispanics, American Indians/Alaska Natives, and Asians and Pacific Islanders. Observed mortality rates were more than 10 times lower in Asians and Pacific Islanders than in whites. The odds of pressure ulcers, urinary tract infections, and pneumonia/influenza being reported on the death certificate were higher in MS deaths than in matched controls.

Earlier onset of treatment or increment in LT4 dose in screened congenital hypothyroidism: which as the more important factor for IQ at 7 years?

OBJECTIVE

To determine between timing and LT4 dose which was the more important factor for IQ at 7 years in screened congenital hypothyroidism (CH).

METHODS

131 children with CH born from 1979 to 1994 and 30 controls were studied. Mean age at recall: 22.8+/-1.1 days. Mean initial LT4:5.6+/-0.1 microg/kg/day.

RESULTS

Optimal global IQ (GIQ; 119+/-1.8) was obtained for a recall < or =15 days. Results for a recall after 3 weeks were lower (107.7 +/- 2.4). The IQ of infants treated before 21 days (117.1 +/-1.2) was identical to the IQ of those treated after this threshold was lower (108.6 +/- 1.7). No significant differences for GIQ were observed with various initial LT4. Infants treated with a dose of LT4 > or = 6 microg/kg/day had a higher performance IQ (117.3 +/-1.8 vs. 112.8+/- 1.2) compared with those treated with a dose < 6 microg/kg/day. The severity of CH and socio-economic levels were similar in all groups.

CONCLUSION

In this study, timing appears to be more important factor for the intellectual outcome.

Children with congenital hypothyroidism are at risk of adult obesity due to early adiposity rebound

OBJECTIVE

There is some evidence that children with congenital hypothyroidism (CH) are heavier than their reference population. There are few data on adults with CH. The timing of adiposity rebound (AR) in childhood has been shown to have strong correlations with adult obesity. Our aims were to study the timing of AR and factors affecting AR in children with CH.

PATIENTS AND METHODS

The timing of AR was examined in a retrospective study of children with CH with growth data at least up to 5 years of age. The proportion of children with CH who reached AR by 37 months and by 49 months of age were compared with healthy children and children with acute lymphoblastic leukaemia (ALL) described in the literature. Correlation of timing of AR with body mass index (BMI) standard deviation score (SDS) at 10 years, initial severity of hypothyroidism and age at normalization of TSH were examined. Multiple logistic regression was used to identify independent factors associated with BMI > or = 20 (overweight) at 10 years of age.

RESULTS

The study included 53 children (34 females and 19 males). AR had occurred by 37 months in 37.7% children with CH, in 42.7% children treated for ALL (CH vs. ALL, P = 0.58) and in 4.5% healthy British children (CH vs. normal, P < 0.0001). We found that 54.7% children with CH had reached AR compared with 21.4% of normal children (CH vs. normal, P < 0.0001) by the age of 49 months. Timing of AR showed significant negative correlation with BMI SDS at 10 years (r = -0.487, P = 0.01). There were no significant relationships between timing of AR and initial thyroid function or age at normalization of TSH. Multiple logistic regression analysis identified age at AR as an independent factor associated with BMI > or = 20 at 10 years of age (P = 0.04).

CONCLUSIONS

Children with CH showed significantly earlier AR compared to normal British children. This showed significant negative correlation with BMI SDS at 10 years. AR in CH does not appear to be directly related to the initial severity of hypothyroidism or to treatment factors.

Head circumference and linear growth during the first 3 years in treated congenital hypothyroidism in relation to aetiology and initial biochemical severity

AIMS

To determine the head circumference and linear growth in children with congenital hypothyroidism (CH) during the first 3 years of life in relation to the aetiology of CH and initial biochemical severity of thyroid function.

METHODS

We examined the head circumference and linear growth of 125 patients with CH from diagnosis up to 3 years of age. All infants had radionuclide scans prior to treatment. Patients were categorized into athyreosis, ectopia and dyshormonogenesis. Occipito-frontal circumference (OFC) SD, length SD, initial plasma TSH, initial plasma thyroxine (T4) and age of suppression of plasma TSH were compared between the groups. Multiple linear regression analysis was used to determine factors affecting OFC SD at 3 years of age.

RESULTS

There were 125 children in the study: athyreosis (n = 34), ectopia (n = 73) and dyshormonogenesis (n = 18). No difference was found in gestation, birth weight, age of starting L-T4 and initial dose of L-T4 in mcg/kg/day between groups. Confirmatory plasma total T4 at diagnosis was significantly lower for athyreosis when compared with ectopia and dyshormonogenesis. Median values for confirmatory TSH were significantly lower in dyshormonogenesis compared with the other two groups. At diagnosis, OFC were similar in all three groups. Children with athyreosis showed significantly larger OFCs compared with ectopia and dyshormonogenesis from 1 to 3 years. Length SD was within 1 SD of normal population standards at diagnosis and did not differ between the three groups throughout the 3 years. Spearman's correlation for OFC SD at 3 years of age showed a significant negative correlation with initial confirmatory plasma T4 (r = -0.35, P = 0.01). Multivariate analysis for OFC SD at 3 years of age showed confirmatory T4 as the only independent risk factor.

CONCLUSION

Children with athyreosis showed significantly larger OFC from 1 to 3 years of age compared with ectopia and dyshormonogenesis, independent of linear growth. Our data shows that initial confirmatory T4 at diagnosis is an independent factor influencing head growth in the first 3 years of life.