Perspective on newborn screening (NBS): evidence sharing on conditions to be included in NBS in Pakistan

Abstract Newborn screening aims at detecting treatable disorders early so that the treatment can be initiated to prevent mortality and morbidity. Such programmes are well established in most developed countries, and all newborns are screened for selected metabolic, endocrine and other disorders based on disease epidemiology, testing and treatment availability, efficiency and cost-effectiveness. Even in developing countries, such screening programmes are initiated using heel prick capillary blood collected on filter paper. The current narrative was planned to provide a perspective with evidence in favour of starting newborn screened for different disorders. The programme project should be initiated nationwide, taking one disorder, congenital hypothyroidism, as the prototype and a newborn screening panel can then be extended to include other disorders. A task force should be set up to recommend disorders to be included in the panel, develop the national plan policies, and define procedures to strengthen the testing.

Newborn screening for congenital hypothyroidism: improvement in short-term follow-up by audit and monitoring

OBJECTIVE

Newborn screening for congenital hypothyroidism (CH) at our hospital during this study was by measurement of thyroid stimulating hormone (TSH) in serum samples. This audit was conducted over a 2 year period, to determine the compliance of reporting of results greater than the screening cutoffs for serum TSH. Gaps of non-compliance were identified, and re-audit was undertaken after the corrective actions were taken.

RESULTS

The critical limit was defined as serum TSH (≥ 20 µIU/ml) following consultation with a pediatric endocrinologist. All results above this limit were reported urgently to physicians. During the audit period, 27,407 tests were performed, 0.7% had a value of ≥ 20 µIU/ml, of those only 62% were reported to the general paediatrician or neonatologist. Reasons for not reporting results included non-availability of contact information, lack of policy awareness by technologists, critical results not highlighted on the computer display, and absence of regular monitoring. Corrective measures were taken, and re-audit was done. During the re-audit period, a total of 22,985 tests was performed, 0.6% had a value of ≥ 20 µIU/ml. Of these, 77% were reported to the general paediatrician or neonatologist. Critical result reporting was improved after the audit, and further enhanced the laboratory service of CH screening.

Lifestyle changes and glycemic control in type 1 diabetes mellitus: a trial protocol with factorial design approach

BACKGROUND

Type 1 diabetes (T1D) has been increasing globally over the past three decades. Self-monitoring of blood glucose is a challenge in both developed as well as developing countries. Self-management guidelines include maintaining logbooks for blood glucose, physical activity, and dietary intake that affect glycated hemoglobin (HbA1c) and a multitude of life-threatening acute complications. Innovative, cost-effective interventions along with beneficial lifestyle modifications can improve home-based self-monitoring of blood glucose in T1D patients. The overall objective of this study is to evaluate the relationship between maintaining log books for blood glucose levels, reinforcement by e-messages, and/or daily step count and changes in HbA1c.

METHODS/DESIGN

A randomized controlled trial will enroll participants aged 15 years and above in four groups. Each group of 30 participants will be working with a newly designed standard log book for documenting their blood glucose. The first group will be entirely on routine clinical care, the second group will be on routine care and will receive an additional e-device for recording step count (fit bit), the third group will receive routine care and daily motivational e-messages to maintain the log book, and the fourth group along with routine care will receive an e-device for measuring step count (fit bit) and e-messages about maintaining the log book. Patients will be enrolled from pediatric and endocrine clinics of a tertiary care hospital in Karachi. All groups will be followed up for a period of 6 months to evaluate outcomes. Log book data will be obtained every 3 months electronically or during a patient's clinic visit. HbA1c as a main outcome will be measured at baseline and will be evaluated twice every 3 months. A baseline questionnaire will determine the socio-demographic, nutritional, and physical activity profile of patients. Clinical information for T1D and other co-morbidities for age of onset, duration, complications, hospitalizations, habits for managing T1D, and other lifestyle characteristics will be ascertained. Behavioral modifications for maintaining daily log books as a routine, following e-messages alone, fit bit alone, or e-messages plus using fit bit will be assessed for changes in HbA1c using a generalized estimated equation.

DISCUSSION

The proposed interventions will help identify whether maintaining log books for blood glucose, motivational e-messages, and/or daily step count will reduce HbA1c levels.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03864991. March 6, 2019.

Comparison of clinical and CSF profiles in children with tuberculous and pyogenic meningitis; role of CSF protein: glucose ratio as diagnostic marker of tuberculous meningitis

OBJECTIVES

To compare the clinical and laboratory features of tuberculous meningitis with bacterial meningitis and to determine if protein glucose ratio in the cerebrospinal fluid can be predictive of the condition.

METHODS

It was a retrospective descriptive study at the Paediatric Ward of Aga Khan University Hospital, Karachi, for which records of 46 patients with tuberculous meningitis and 33 with bacterial meningitis were reviewed. All records related to the study period that was from January 2005 to October 2010. The records were retrieved in December 2010. Tuberculous meningitis was defined as illness > or = 14 days, basal enhancement or tuberculoma on computerised tomography scan and response to anti-tuberculous therapy. Pyogenic meningitis was defined by the presence of a pathogenic isolate inthe cerebrospinal fluid (bacterial culture) or by positive latex particle agglutination or a pathogen on cerebrospinal fluid gram stain and clinical improvement with antibiotics. Logistic regression was used to model the probability of having tuberculous meningitis. To define the optimal protein-glucose ratio, cutoff point for the diagnosis of tuberculous meningitis, a receiver operating characteristic curve was applied. All analysis were done using SPSS 16.

RESULTS

Features predictive of a diagnosis of tuberculous meningitis were protein:glucose ratio of > or = 2 (OR 21 95% CI 4.7-93); cerebrospinal fluid total leukocyte count < 800 (OR 58, 95% CI 5-649); and the presence of hydrocephalus (OR 19, 95% CI 3.3-109).

CONCLUSION

A set of simple clinical, laboratory and radiological criteria can help in predicting tuberculous meningitis. The value of cerebrospinal fluid protein:glucose ratio needs to be validated in larger studies with bacteriologically-confirmed cases of tuberculous meningitis.

Setting research priorities for preconception care in low- and middle-income countries: aiming to reduce maternal and child mortality and morbidity

Sohni Dean and colleagues report their CHNRI exercise that developed health research priorities for effective pre-conception care in low- and middle-income countries. Please see later in the article for the Editors' Summary

Asthma in children: management issues for family doctors

Asthma is still one of the leading causes of morbidity in children. Despite the improved understanding in the disease pathogenesis and availability of the different classes of drugs, the incidence of emergency visits due to acute exacerbations and admission rates due to frequent and uncontrolled disease is fairly high. Management of bronchial asthma in children is quite different to that of adults. Although there are universal guidelines available for the management of childhood asthma, there is still confusion especially among the family physicians who are largely involved in the management of the children, both in acute exacerbations as well as in long term prevention. This article aims to simplify all the management issues for family physicians in concurrence with the available asthma management guidelines.