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He Z, Dai H, Shen J, Huang Y, Liu J, Yan R, Zhang F, Yan S. Development and evaluation of a candidate reference measurement procedure for detecting 17α-hydroxyprogesterone in dried blood spots using isotope dilution liquid chromatography tandem mass spectrometry. Anal Bioanal Chem 2024:10.1007/s00216-024-05411-9. [PMID: 38949681 DOI: 10.1007/s00216-024-05411-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/12/2024] [Accepted: 06/17/2024] [Indexed: 07/02/2024]
Abstract
17α-Hydroxyprogesterone (17α-OHP) quantification in dried blood spots (DBS) is essential for newborn screening for congenital adrenal hyperplasia (CAH), which is challenging due to its low physiological concentration. The high false-positive rates of immunoassays necessitate the development of more accurate methods. Liquid chromatography tandem mass spectrometry (LC-MS/MS) offers increased specificity and sensitivity, yet standardized procedures for 17α-OHP measurement are required for clinical application. A candidate reference measurement procedure (cRMP) using isotope dilution LC-MS/MS was developed for 17α-OHP quantification in DBS. By utilizing stable isotope-labeled D8-17α-OHP as an internal standard, the cRMP was optimized, covering sample preparation, calibration, and LC-MS/MS analysis. The method performance was validated across several parameters, including precision, accuracy, specificity, detection limits, and matrix effects. Clinical applicability was further assessed through the establishment of reference intervals for healthy newborns. The developed cRMP exhibited a linear range of 1.00 to 80.00 ng/mL for 17α-OHP, with detection and quantification limits of 0.14 ng/mL and 0.52 ng/mL, respectively. Inter- and intraday precision demonstrated coefficients of variation within 1.27 to 5.69%. The recovery rates and matrix effects were well within acceptable limits, ensuring method reliability. Clinical application showed distinct reference intervals for healthy newborns that were unaffected by sex but influenced by weight and gestational age. This method significantly enhances CAH diagnostic accuracy in newborns, providing a valuable tool for clinical laboratories and improving newborn screening program standardization and traceability.
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Affiliation(s)
- Ziyun He
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
- College of Laboratory Medicine, Zunyi Medical University, Zunyi, 563000, China
| | - Haibing Dai
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
- College of Laboratory Medicine, Zunyi Medical University, Zunyi, 563000, China
| | - Jian Shen
- Guangzhou Fenghua Biotech Co., Ltd., Guangzhou, 510730, China
| | - Yanjie Huang
- Guangdong Provincial Institute of Metrology, South China National Centre of Metrology, Guangzhou, 510405, China
| | - Jinsong Liu
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
- College of Laboratory Medicine, Zunyi Medical University, Zunyi, 563000, China
| | - Renqing Yan
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
- College of Laboratory Medicine, Zunyi Medical University, Zunyi, 563000, China
| | - Feng Zhang
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China
- College of Laboratory Medicine, Zunyi Medical University, Zunyi, 563000, China
| | - Shengkai Yan
- Department of Laboratory Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563003, China.
- College of Laboratory Medicine, Zunyi Medical University, Zunyi, 563000, China.
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2
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Graves LE, van Dijk EB, Zhu E, Koyyalamudi S, Wotton T, Sung D, Srinivasan S, Ginn SL, Alexander IE. AAV-delivered hepato-adrenal cooperativity in steroidogenesis: Implications for gene therapy for congenital adrenal hyperplasia. Mol Ther Methods Clin Dev 2024; 32:101232. [PMID: 38558568 PMCID: PMC10979120 DOI: 10.1016/j.omtm.2024.101232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 03/08/2024] [Indexed: 04/04/2024]
Abstract
Despite the availability of life-saving corticosteroids for 70 years, treatment for adrenal insufficiency is not able to recapitulate physiological diurnal cortisol secretion and results in numerous complications. Gene therapy is an attractive possibility for monogenic adrenocortical disorders such as congenital adrenal hyperplasia; however, requires further development of gene transfer/editing technologies and knowledge of the target progenitor cell populations. Vectors based on adeno-associated virus are the leading system for direct in vivo gene delivery but have limitations in targeting replicating cell populations such as in the adrenal cortex. One strategy to overcome this technological limitation is to deliver the relevant adrenocortical gene to a currently targetable organ outside of the adrenal cortex. To explore this possibility, we developed a vector encoding human 21-hydroxylase and directed expression to the liver in a mouse model of congenital adrenal hyperplasia. This extra-adrenal expression resulted in reconstitution of the steroidogenic pathway. Aldosterone and renin levels normalized, and corticosterone levels improved sufficiently to reduce adrenal hyperplasia. This strategy could provide an alternative treatment option for monogenic adrenal disorders, particularly for mineralocorticoid defects. These findings also demonstrate, when targeting the adrenal gland, that inadvertent liver transduction should be precluded as it may confound data interpretation.
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Affiliation(s)
- Lara E. Graves
- Gene Therapy Research Unit, Children’s Medical Research Institute, Faculty of Medicine and Health, The University of Sydney and Sydney Children’s Hospitals Network, Westmead, NSW 2145, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Westmead, NSW 2145, Australia
- Institute of Endocrinology and Diabetes, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Eva B. van Dijk
- Gene Therapy Research Unit, Children’s Medical Research Institute, Faculty of Medicine and Health, The University of Sydney and Sydney Children’s Hospitals Network, Westmead, NSW 2145, Australia
| | - Erhua Zhu
- Gene Therapy Research Unit, Children’s Medical Research Institute, Faculty of Medicine and Health, The University of Sydney and Sydney Children’s Hospitals Network, Westmead, NSW 2145, Australia
| | - Sundar Koyyalamudi
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Westmead, NSW 2145, Australia
- Institute of Endocrinology and Diabetes, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Tiffany Wotton
- NSW Newborn Screening Program, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Dinah Sung
- NSW Newborn Screening Program, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Shubha Srinivasan
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Westmead, NSW 2145, Australia
- Institute of Endocrinology and Diabetes, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia
| | - Samantha L. Ginn
- Gene Therapy Research Unit, Children’s Medical Research Institute, Faculty of Medicine and Health, The University of Sydney and Sydney Children’s Hospitals Network, Westmead, NSW 2145, Australia
| | - Ian E. Alexander
- Gene Therapy Research Unit, Children’s Medical Research Institute, Faculty of Medicine and Health, The University of Sydney and Sydney Children’s Hospitals Network, Westmead, NSW 2145, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Westmead, NSW 2145, Australia
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Therrell BL, Padilla CD, Borrajo GJC, Khneisser I, Schielen PCJI, Knight-Madden J, Malherbe HL, Kase M. Current Status of Newborn Bloodspot Screening Worldwide 2024: A Comprehensive Review of Recent Activities (2020-2023). Int J Neonatal Screen 2024; 10:38. [PMID: 38920845 PMCID: PMC11203842 DOI: 10.3390/ijns10020038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 06/27/2024] Open
Abstract
Newborn bloodspot screening (NBS) began in the early 1960s based on the work of Dr. Robert "Bob" Guthrie in Buffalo, NY, USA. His development of a screening test for phenylketonuria on blood absorbed onto a special filter paper and transported to a remote testing laboratory began it all. Expansion of NBS to large numbers of asymptomatic congenital conditions flourishes in many settings while it has not yet been realized in others. The need for NBS as an efficient and effective public health prevention strategy that contributes to lowered morbidity and mortality wherever it is sustained is well known in the medical field but not necessarily by political policy makers. Acknowledging the value of national NBS reports published in 2007, the authors collaborated to create a worldwide NBS update in 2015. In a continuing attempt to review the progress of NBS globally, and to move towards a more harmonized and equitable screening system, we have updated our 2015 report with information available at the beginning of 2024. Reports on sub-Saharan Africa and the Caribbean, missing in 2015, have been included. Tables popular in the previous report have been updated with an eye towards harmonized comparisons. To emphasize areas needing attention globally, we have used regional tables containing similar listings of conditions screened, numbers of screening laboratories, and time at which specimen collection is recommended. Discussions are limited to bloodspot screening.
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Affiliation(s)
- Bradford L. Therrell
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
- National Newborn Screening and Global Resource Center, Austin, TX 78759, USA
| | - Carmencita D. Padilla
- Department of Pediatrics, College of Medicine, University of the Philippines Manila, Manila 1000, Philippines;
| | - Gustavo J. C. Borrajo
- Detección de Errores Congénitos—Fundación Bioquímica Argentina, La Plata 1908, Argentina;
| | - Issam Khneisser
- Jacques LOISELET Genetic and Genomic Medical Center, Faculty of Medicine, Saint Joseph University, Beirut 1104 2020, Lebanon;
| | - Peter C. J. I. Schielen
- Office of the International Society for Neonatal Screening, Reigerskamp 273, 3607 HP Maarssen, The Netherlands;
| | - Jennifer Knight-Madden
- Caribbean Institute for Health Research—Sickle Cell Unit, The University of the West Indies, Mona, Kingston 7, Jamaica;
| | - Helen L. Malherbe
- Centre for Human Metabolomics, North-West University, Potchefstroom 2531, South Africa;
- Rare Diseases South Africa NPC, The Station Office, Bryanston, Sandton 2021, South Africa
| | - Marika Kase
- Strategic Initiatives Reproductive Health, Revvity, PL10, 10101 Turku, Finland;
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Greaves RF, Kumar M, Mawad N, Francescon A, Le C, O’Connell M, Chi J, Pitt J. Best Practice for Identification of Classical 21-Hydroxylase Deficiency Should Include 21 Deoxycortisol Analysis with Appropriate Isomeric Steroid Separation. Int J Neonatal Screen 2023; 9:58. [PMID: 37873849 PMCID: PMC10594498 DOI: 10.3390/ijns9040058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/18/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
There are mixed reports on the inclusion and use of 21 deoxycortisol (21DF) as the primary decision marker for classical 21-hydroxylase deficiency. We hypothesize that this may be due to insufficient recognition of the presence and chromatographic separation of isomeric steroids. The aim of this study was to determine the comparative utility of 21DF for screening and diagnosis of CAH due to classical 21-hydroxylase deficiency using a second-tier LC-MS/MS method that included the separation of isomeric steroids to 17OHP and 21DF. For each baby sample, one 3.2 mm dried blood spot was eluted in a methanolic solution containing isotopically matched internal standards. Data were interrogated by univariate and receiver operator characteristic analysis. Steroid profile results were generated for 924 non-CAH baby samples (median gestational age 37 weeks, range 22 to 43 weeks) and 17 babies with 21-hydroxylase deficiency. The ROC curves demonstrated 21DF to have the best sensitivity and specificity for the diagnosis of classical 21-hydroxylase deficiency with an AUC = 1.0. The heatmap showed the very strong correlation (r = 0.83) between 17OHP and 21DF. Our data support 21DF as a robust marker for CAH due to 21-hydroxylase deficiency. We recommend that 21DF be incorporated into routine newborn screening panels as part of the second-tier LC-MS/MS method, follow-up plasma steroid panels, and external quality assurance material.
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Affiliation(s)
- Ronda F. Greaves
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia;
| | - Monish Kumar
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - Nazha Mawad
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - Alberto Francescon
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - Chris Le
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - Michele O’Connell
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia;
- Department of Endocrinology, The Royal Children’s Hospital, Parkville, VIC 3052, Australia
| | - James Chi
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
| | - James Pitt
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia; (M.K.); (N.M.); (A.F.); (C.L.); (J.C.); (J.P.)
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3052, Australia;
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de Hora M, Heather N, Webster D, Albert B, Hofman P. The use of liquid chromatography-tandem mass spectrometry in newborn screening for congenital adrenal hyperplasia: improvements and future perspectives. Front Endocrinol (Lausanne) 2023; 14:1226284. [PMID: 37850096 PMCID: PMC10578435 DOI: 10.3389/fendo.2023.1226284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/12/2023] [Indexed: 10/19/2023] Open
Abstract
Newborn screening for congenital adrenal hyperplasia using 17-hydroxyprogesterone by immunoassay remains controversial despite screening been available for almost 40 years. Screening is confounded by poor immunoassay specificity, fetal adrenal physiology, stress, and illness which can result in a large number of false positive screening tests. Screening programmes apply higher screening thresholds based on co-variates such as birthweight or gestational age but the false positive rate using immunoassay remains high. Mass spectrometry was first applied to newborn screening for congenital adrenal hyperplasia over 15 years ago. Elevated 17-hydroxprogesterone by immunoassay can be retested with a specific liquid chromatography tandem mass spectrometry assay that may include additional steroid markers. Laboratories register with quality assurance programme providers to ensure accurate steroid measurements. This has led to improvements in screening but there are additional costs and added laboratory workload. The search for novel steroid markers may inform further improvements to screening. Studies have shown that 11-oxygenated androgens are elevated in untreated patients and that the adrenal steroidogenesis backdoor pathway is more active in babies with congenital adrenal hyperplasia. There is continual interest in 21-deoxycortisol, a specific marker of 21-hydroxylase deficiency. The measurement of androgenic steroids and their precursors by liquid chromatography tandem mass spectrometry in bloodspots may inform improvements for screening, diagnosis, and treatment monitoring. In this review, we describe how liquid chromatography tandem mass spectrometry has improved newborn screening for congenital adrenal hyperplasia and explore how future developments may inform further improvements to screening and diagnosis.
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Affiliation(s)
- Mark de Hora
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Natasha Heather
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Dianne Webster
- Newborn Screening, Specialist Chemical Pathology, LabPlus, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Benjamin Albert
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Paul Hofman
- Clinical Research Unit, Liggins Institute, University of Auckland, Auckland, New Zealand
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Conlon TA, Hawkes CP, Brady JJ, Loeber JG, Murphy N. International Newborn Screening Practices for the Early Detection of Congenital Adrenal Hyperplasia. Horm Res Paediatr 2023; 97:113-125. [PMID: 37231960 DOI: 10.1159/000530754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/11/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Newborn screening (NBS) programmes vary internationally in their approach to screening. Guidelines for congenital adrenal hyperplasia (CAH) screening recommend the use of two-tier testing and gestational age cutoffs to minimise false-positive results. The aims of this study were to describe (1) the approaches; (2) protocols used; and (3) available outcomes for CAH screening internationally. METHODS All members of the International Society for Neonatal Screening were asked to describe their CAH NBS protocols, with an emphasis on the use of second-tier testing, 17-hydroxyprogesterone (17OHP) cutoffs, and gestational age and birth weight adjustments. If available, screening outcomes were requested. RESULTS Representatives from 23 screening programmes provided data. Most (n = 14; 61%) recommend sampling at 48-72 h of life. Fourteen (61%) use single-tier testing and 9 have a two-tier testing protocol. Gestational age cutoffs are used in 10 programmes, birth weight cutoffs in 3, and a combination of both in 9. One programme does not use either method of adjusting 17OHP cutoffs. Case definition of a positive test and the response to a positive test differed between programmes. CONCLUSIONS We have demonstrated significant variation across all aspects of NBS for CAH, including timing, the use of single versus two-tier testing and cutoff interpretation. Collaboration between international screening programmes and implementation of new techniques to improve screen efficacy will facilitate ongoing expansion and quality improvement in CAH NBS.
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Affiliation(s)
- Tracey A Conlon
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Colin P Hawkes
- INFANT Research Centre, University College Cork, Cork, Ireland
- Perelman School of Medicine, University of Pennsylvania, PA, Philadelphia, USA
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jennifer J Brady
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Paediatric Laboratory Medicine, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - J Gerard Loeber
- Office of the International Society for Neonatal Screening, Maarssen, The Netherlands
| | - Nuala Murphy
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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Tippabathani J, Seenappa V, Murugan A, Phani NM, Hampe MH, Appaswamy G, Sadashiv Gambhir P. Neonatal Screening for Congenital Adrenal Hyperplasia in Indian Newborns with Reflex Genetic Analysis of 21-Hydroxylase Deficiency. Int J Neonatal Screen 2023; 9:ijns9010009. [PMID: 36975848 PMCID: PMC10053538 DOI: 10.3390/ijns9010009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/25/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH), screened for in neonates, is the second most common endocrinopathy after congenital hypothyroidism.Newborn screening for CAH due to CYP21A2 deficiency is performed by immunologic assay for 17-hydroxyprogesterone (17-OHP). The second-tier test for confirmation of diagnosis is carried out on recall venous blood sample from screen positives measuring 17-OHP, or other metabolites of steroid metabolism by liquid chromatography–tandem mass spectroscopy. However, as steroid metabolism is dynamic, it can affect these parameters even in the recall sample of a stressed neonate. Moreover, there is some time delay in recalling the neonate for repeat testing. Reflex genetic analysis of blood spot from the initial Guthrie cards of screen positive neonates, if used for confirmatory testing, can avoid this time delay as well as the effect of stress on steroid metabolism. In this study, we used Sanger sequencing and MLPA in a reflex manner for molecular genetic analysis to confirm CYP21A2-mediated CAH. Out of 220,000 newborns screened, 97 were positive on the initial biochemical screen, of which 54 were confirmed true positives with genetic reflex testing, giving incidence of CAH as 1:4074. Point mutations were more common than deletions, indicating that Sanger sequencing should be used ahead of MLPA for molecular diagnosis in India. Amongst the variants detected, the most common was I2G-Splice variant (44.5%), followed by c.955C>T (p.Gln319Ter) (21.2%); Del 8 bp and c.-113G>A were detected with frequencies of 20.3% and 20%, respectively. In conclusion, reflex genetic testing is an effective strategy for identifying true positives in CAH screening in neonates. This will obviate need for recall samples and also aid effective counselling and timely prenatal diagnosis in the future. In Indian newborns, as point mutations are more common than large deletions, Sanger sequencing should be the initial method of choice for genotyping, ahead of MLPA.
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Affiliation(s)
| | - Venu Seenappa
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
| | - Alagupandian Murugan
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
| | | | - Mahesh H. Hampe
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
| | - Giridharan Appaswamy
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
| | - Prakash Sadashiv Gambhir
- Lifecell International Pvt Ltd., Vandalur, Kelambakkam Road, Chennai 600127, India
- Chief Medical Scientist, Lifecell, West Regional Lab, Pune 411048, India
- Correspondence:
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Rodrigues F, Zacharin M. Congenital adrenal hyperplasia: The importance of screening and clinical assessment. J Paediatr Child Health 2023; 59:182-184. [PMID: 36129252 DOI: 10.1111/jpc.16225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/27/2022] [Accepted: 09/05/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Farrah Rodrigues
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Margaret Zacharin
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Watanabe K, Tsuji-Hosokawa A, Hashimoto A, Konishi K, Ishige N, Yajima H, Sutani A, Nakatani H, Gau M, Takasawa K, Tajima T, Hasegawa T, Morio T, Kashimada K. The High Relevance of 21-Deoxycortisol, (Androstenedione + 17α-Hydroxyprogesterone)/Cortisol, and 11-Deoxycortisol/17α-Hydroxyprogesterone for Newborn Screening of 21-Hydroxylase Deficiency. J Clin Endocrinol Metab 2022; 107:3341-3352. [PMID: 36071550 DOI: 10.1210/clinem/dgac521] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT There are limited reports on the detailed examination of steroid profiles for setting algorithms for 21-hydroxylase deficiency (21OHD) screening by liquid chromatography-tandem mass spectrometry (LC-MS/MS). OBJECTIVE We aimed to define an algorithm for newborn screening of 21OHD by LC-MS/MS, measuring a total of 2077 dried blood spot samples in Tokyo. METHODS Five steroids (17α-hydroxyprogesterone [17αOHP], 21-deoxycortisol [21DOF], 11-deoxycortisol [11DOF], androstenedione [4AD], and cortisol [F]) were included in the panel of LC-MS/MS. Samples from 2 cohorts were assayed: Cohort A, 63 "screening positive" neonates who were referred to an endocrinologist (n = 26 with 21OHD; n = 37 false-positive; obtained from 2015 to 2020); and Cohort B, samples (n = 2014) with 17αOHP values in the 97th percentile or above, in the first-tier test with 17αOHP ELISA from 2020 to 2021. RESULTS Analysis of Cohort A revealed that the 3 indexes 21DOF, 11DOF/17αOHP, and (4AD + 17αOHP)/F had higher area under the curve (AUC) values (0.999, 0.997, 0.989, respectively), while the 17αOHP AUC was lower (0.970). Accordingly, in addition to 17αOHP, the 3 markers were included for defining the screening algorithm. The assay of Cohort B revealed that the new algorithm gave 92% of predicted positive predictive value without false-negative cases. We also determined the reference values for the 5 steroids at 4 to 7 days after birth, according to sex and gestational age (GA), revealing extremely low levels of 21DOF at any GA irrespective of sex differences. CONCLUSION Our study demonstrated the high relevance of 21DOF, (4AD + 17αOHP)/F, and 11DOF/17αOHP, rather than 17αOHP, for 21OHD screening.
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Affiliation(s)
| | - Atsumi Tsuji-Hosokawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Atsuko Hashimoto
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Kaoru Konishi
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Nobuyuki Ishige
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Harumi Yajima
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Akito Sutani
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Hisae Nakatani
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
| | - Maki Gau
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Toshihiro Tajima
- Department of Pediatrics, Jichi Medical University, Tochigi 329-0498, Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics, Keio University, School of Medicine, Tokyo 160-8582, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
| | - Kenichi Kashimada
- Tokyo Health Service Association, Newborn Screening, Tokyo, Japan
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo 113-8510, Japan
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Evaluation of a New Laboratory Protocol for Newborn Screening for Congenital Adrenal Hyperplasia in New Zealand. Int J Neonatal Screen 2022; 8:ijns8040056. [PMID: 36278626 PMCID: PMC9590017 DOI: 10.3390/ijns8040056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
Between 2005 and 2021, 49 cases of classical congenital adrenal hyperplasia were diagnosed in New Zealand, 39 were detected in newborns and 10 were not detected by screening. Currently, for every case of CAH detected by screening, 10 false-positive tests are encountered. Second-tier liquid chromatography-tandem mass spectrometry (LCMSMS) has the potential to improve screening sensitivity and specificity. A new laboratory protocol for newborn screening for CAH was evaluated. Birthweight-adjusted thresholds for first- and second-tier 17-hydroxyprogesterone, second-tier 21-deoxycortisol and a steroid ratio were applied to 4 years of newborn screening data. The study was enriched with 35 newborn screening specimens from confirmed CAH cases. Newborn screening was conducted on 232,542 babies, and 11 cases of classical CAH were detected between 2018 and 2021. There were 98 false-positive tests (specificity 99.96%, PPV = 10.1%) using the existing protocol. Applying the new protocol, the same 11 cases were detected, and there were 13 false-positive tests (sensitivity > 99.99%, PPV = 45.8%, (X2 test p < 0.0001). Incorporating the retrospective specimens, screening sensitivity for classical CAH was 78% (existing protocol), compared to 87% for the new protocol (X2 test p = 0.1338). Implementation of LCMSMS as a second-tier test will improve newborn screening for classical CAH in New Zealand.
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Saltarelli MA, Ferrante R, Marcello FD, David D, Valentinuzzi S, Pilenzi L, Federici L, Rossi C, Stuppia L, Tumini S. A Novel Heterozygous Mutation of the CYP17A1 Gene in a Child with a Micropenis and Isolated 17,20-Lyase Deficiency. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116880. [PMID: 35682463 PMCID: PMC9180258 DOI: 10.3390/ijerph19116880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 02/05/2023]
Abstract
Disorders of sexual development (DSDs) are characterized by a heterogeneous group of congenital conditions associated with atypical development of the sex chromosomes, gonadal or anatomical sex. We report the case of a child with an isolated micropenis, a typical feature of the 46,XY DSD showing low basal testosterone levels and post-stimulation with the hCG test. Molecular analysis using a next-generation sequencing (NGS) panel of 50 genes involved in DSDs was performed, revealing a heterozygous mutation, c.1040G > ANM_000102.4, in the CYP17A1 gene. Sanger sequencing was used to confirm the gene variant detected by NGS; it was also performed to his parents, revealing the presence of the same mutation in the mother, who presented no features of the disease. Then, the serum steroid profile was determined by liquid chromatography coupled to tandem mass spectrometry analysis. Interestingly, this analysis highlighted low levels of testosterone, progesterone, and dehydroepiandrostenedione, as also confirmed by a stimulus test with ACTH. These results suggest that, in some cases, heterozygous mutations in recessive genes involved in adrenal steroidogenesis can also affect the patient’s phenotype.
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Affiliation(s)
- Maria Alessandra Saltarelli
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Chieti Hospital, 66100 Chieti, Italy; (M.A.S.); (F.D.M.); (D.D.); (S.T.)
| | - Rossella Ferrante
- Department of Psychological, Health and Territory Sciences, School of Medicine and Health Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (L.P.); (C.R.); (L.S.)
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (L.F.)
- Correspondence:
| | - Francesca Di Marcello
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Chieti Hospital, 66100 Chieti, Italy; (M.A.S.); (F.D.M.); (D.D.); (S.T.)
| | - Daniela David
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Chieti Hospital, 66100 Chieti, Italy; (M.A.S.); (F.D.M.); (D.D.); (S.T.)
| | - Silvia Valentinuzzi
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (L.F.)
- Department of Pharmacy, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Lucrezia Pilenzi
- Department of Psychological, Health and Territory Sciences, School of Medicine and Health Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (L.P.); (C.R.); (L.S.)
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (L.F.)
| | - Luca Federici
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (L.F.)
- Department of Innovative Technologies in Medicine and Dentistry, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Claudia Rossi
- Department of Psychological, Health and Territory Sciences, School of Medicine and Health Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (L.P.); (C.R.); (L.S.)
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (L.F.)
| | - Liborio Stuppia
- Department of Psychological, Health and Territory Sciences, School of Medicine and Health Sciences, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (L.P.); (C.R.); (L.S.)
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy; (S.V.); (L.F.)
| | - Stefano Tumini
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Chieti Hospital, 66100 Chieti, Italy; (M.A.S.); (F.D.M.); (D.D.); (S.T.)
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Lind-Holst M, Bækvad-Hansen M, Berglund A, Cohen AS, Melgaard L, Skogstrand K, Duno M, Main KM, Hougaard DM, Gravholt CH, Hansen D. Neonatal Screening for Congenital Adrenal Hyperplasia in Denmark: 10 Years of Experience. Horm Res Paediatr 2022; 95:35-42. [PMID: 35114680 DOI: 10.1159/000522230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/14/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Early detection of salt-wasting congenital adrenal hyperplasia (SW-CAH) is important to reduce CAH-related morbidity. However, neonatal screening has shown to have a low positive predictive value (PPV), especially among preterm newborns. Here, the Danish CAH screening is evaluated by comparing incidence and morbidity of SW-CAH 10 years before and after introduction of screening. Furthermore, sensitivity, specificity, and PPV are determined. METHODS All newborns in Denmark born during 1999-2018 and diagnosed with SW-CAH were identified in the Danish National Patient Registry and/or at the Department of Clinical Genetics, Rigshospitalet. Newborns with a positive neonatal CAH screening were identified at Statens Serum Institut. Correct diagnosis was evaluated by medical record review. RESULTS A total of 65 newborns with SW-CAH were identified. The incidence of SW-CAH was 5:100,000 both before and after introduction of screening. Performance of sensitivity and specificity of the screening were 97% and 100%, respectively, and the PPV was 55% for the given period. Stratified according to gestational age, the PPV was 33% and 61% for pre -and fullterm newborns, respectively. Though not significant, the proportion of newborns presenting with SW-crisis decreased after introduction of screening from 29% versus 10% (p = 0.07). DISCUSSION AND CONCLUSION Neonatal screening for SW-CAH has not led to an increase in the incidence of newborns diagnosed with SW-CAH. The screening algorithm has effectively identified newborns with SW-CAH. After 2009, there was a tendency toward a lower proportion of newborns with SW-crisis at diagnosis. Finally, the study emphasizes the benefits of using second-tier screening as well as repeated screening of premature newborns.
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Affiliation(s)
- Marie Lind-Holst
- Department of Pediatrics, Hans Christian Andersen Children's Hospital, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Marie Bækvad-Hansen
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Agnethe Berglund
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark.,Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Arieh S Cohen
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Lars Melgaard
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Kristin Skogstrand
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Morten Duno
- Department of Clinical Genetics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Katharina M Main
- Department of Growth and Reproduction and EDMaRC, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
| | - David Michael Hougaard
- Department for Congenital Disorders, Danish Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
| | - Claus Højbjerg Gravholt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Dorte Hansen
- Department of Pediatrics, Hans Christian Andersen Children's Hospital, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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Nordenström A, Falhammar H, Lajic S. Current and Novel Treatment Strategies in Children with Congenital Adrenal Hyperplasia. Horm Res Paediatr 2022; 96:560-572. [PMID: 35086098 DOI: 10.1159/000522260] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The standard treatment for congenital adrenal hyperplasia (CAH) in children is still hydrocortisone. Improved strategies for timing of the dose during the day and the dose per square meter body surface area used in children of different ages and developmental phases have improved the situation and outcome for the patients. Neonatal screening enables an earlier diagnosis and initiation of treatment, prevents from adrenal crisis, and improves growth and development also for children with the less severe forms of CAH. SUMMARY This review describes the current treatment strategies for children with CAH and discusses some potential treatment options that have been developed with the primary aim to decrease the adrenal androgen production. Novel modified release glucocorticoid therapies are also discussed. KEY MESSAGES The long-term effects of the new adjunct therapies are unknown, and some are not suitable for use in children and adolescents. The effects of the new therapies on bone mineral density, gonadal functions, and long-term cognitive development are yet to be assessed. It is not known what levels of adrenal androgens are optimal for normal growth, puberty, and bone health. The basis of using glucocorticoids and mineralocorticoids in the treatment of CAH remains, and in some individuals, it may be beneficial to add therapies to reduce the androgen load during certain life stages.
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Affiliation(s)
- Anna Nordenström
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Department of Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 157] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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15
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Conlon TA, Hawkes CP, Brady JJ, Murphy NP. The presentation of congenital adrenal hyperplasia in an unscreened population. J Pediatr Endocrinol Metab 2021; 34:1123-1129. [PMID: 34167176 DOI: 10.1515/jpem-2021-0123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/12/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this study was to describe the incidence and spectrum of early clinical presentations of congenital adrenal hyperplasia (CAH) in an unscreened population. METHODS A national retrospective observational study was undertaken to identify all children diagnosed with CAH in the Republic of Ireland, between January 2005 and December 2019. Reporting clinicians completed anonymized clinical questionnaires. RESULTS There were 103 cases of CAH reported and 69 cases met the study inclusion criteria. The estimated annualized incidence of CAH in the Republic of Ireland was 1:14,754 or 0.07 cases per 1,000 live births. Forty-seven children presented clinically in the first six months of life, but only 17 of these had a confirmed diagnosis by day 10. Of these early presentations, there were 28 infants with salt-wasting, 15 females presented with virilized genitalia and four infants were detected due to a family history of CAH. Female infants presented at a median age of 0 days [IQR 0-1] and males at 14 days [IQR 9-21]. Seventy-eight percent of salt-wasting presentations occurred after day 10. Delays in clinical presentation, biochemical diagnosis and treatment initiation were identified. CONCLUSIONS The incidence of CAH is higher in Ireland than in other unscreened populations. In the absence of screening, clinicians should be aware of the possibility of CAH and appropriate investigations should be urgently requested. Life-threatening salt-wasting is the most frequent clinical presentation and many cases could be detected prior to decompensation if newborn screening were introduced.
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Affiliation(s)
- Tracey A Conlon
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin 1, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Colin P Hawkes
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jennifer J Brady
- Department of Clinical Biochemistry, Children's Health Ireland at Temple Street, Dublin 1, Ireland
| | - Nuala P Murphy
- Department of Paediatric Endocrinology, Children's Health Ireland at Temple Street, Dublin 1, Ireland.,School of Medicine, University College Dublin, Dublin 4, Ireland
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Van Vliet G, Grosse SD. [Newborn screening for congenital hypothyroidism and congenital adrenal hyperplasia: Benefits and costs of a successful public health program]. Med Sci (Paris) 2021; 37:528-534. [PMID: 34003099 PMCID: PMC8387970 DOI: 10.1051/medsci/2021053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Newborn screening is an important public health program and a triumph of preventive medicine. Economic analyses show that the benefits of newborn screening clearly outweigh the costs for certain diseases, but not necessarily for other ones. This is due to the great diversity of the natural history of the diseases detected, to the fact that each of these diseases considered individually is rare, and to differences in the effectiveness of interventions. In addition, the benefit-cost ratio of screening for a particular disorder may differ between countries, specifically between high-income and low- and middle-income countries. The burden of a disorder may also be alleviated by increased clinical awareness and effective clinical services, even in the absence of newborn screening. In this article, we focus on economic analyses of newborn screening for primary congenital hypothyroidism, which has been in place in high-income countries for roughly 40 years, and for classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Screening for the latter is not yet universal, even in high-income countries, although the lack of universal implementation may reflect factors other than economic considerations.
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Affiliation(s)
- Guy Van Vliet
- Service d'endocrinologie et Centre de recherche, Centre hospitalier universitaire Sainte-Justine et Département de pédiatrie, Université de Montréal, 3175 Côte Sainte-Catherine, Montréal (Québec) H3T 1C5, Canada
| | - Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 4770 Buford Highway, Atlanta, GA, 30341, États-Unis
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17
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Newborn Screening for CAH-Challenges and Opportunities. Int J Neonatal Screen 2021; 7:ijns7010011. [PMID: 33668620 PMCID: PMC8006248 DOI: 10.3390/ijns7010011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/09/2021] [Accepted: 02/09/2021] [Indexed: 12/01/2022] Open
Abstract
Newborn screening for congenital adrenal hyperplasia (CAH) using 17-hydroxyprogesterone (17-OHP) as an indicator of disease was first introduced in the 1970s [...].
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18
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Grosse SD, Van Vliet G. Challenges in Assessing the Cost-Effectiveness of Newborn Screening: The Example of Congenital Adrenal Hyperplasia. Int J Neonatal Screen 2020; 6:E82. [PMID: 33239603 PMCID: PMC7712219 DOI: 10.3390/ijns6040082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 12/27/2022] Open
Abstract
Generalizing about the cost-effectiveness of newborn screening (NBS) is difficult due to the heterogeneity of disorders included in NBS panels, along with data limitations. Furthermore, it is unclear to what extent evidence about cost-effectiveness should influence decisions to screen for specific disorders. Screening newborns for congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency can serve as a useful test case, since there is no global consensus on whether CAH should be part of NBS panels. Published and unpublished cost-effectiveness analyses of CAH screening have yielded mixed findings, largely due to differences in methods and data sources for estimating health outcomes and associated costs of early versus late diagnosis as well as between-country differences. Understanding these methodological challenges can help inform future analyses and could also help interested policymakers interpret the results of economic evaluations.
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Affiliation(s)
- Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Guy Van Vliet
- Endocrinology Service and Research Center of the Sainte-Justine Hospital and Department of Pediatrics, University of Montreal, Montreal, QC H3T 1C5, Canada;
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