Four years of expanded newborn screening in Portugal with tandem mass spectrometry

INTRODUCTION

The Portuguese Neonatal Screening Programme (PNSP) was started in 1979 for phenylketonuria (2,590,700 newborns screened; prevalence 1:11,031) and, shortly after, for congenital hypothyroidism (2,558,455 newborns screened; prevalence 1:3,174). In 2004, expanded neonatal screening was implemented in the National Laboratory. The programme is not mandatory and has 99.8% coverage of the country (including Madeira and the Azores islands).

MATERIAL AND METHODS

In the past 4 years, 316,243 neonates were screened with the use of tandem mass spectrometry (MS/MS) to test for selected amino acids and acylcarnitines.

RESULTS

During this time, 132 patients were identified with 24 different inherited metabolic diseases (classic forms and variants). To date, the global frequency for all disorders integrated into the PNSP is estimated to be 1:1,380, with 1:2,396 for metabolic disorders. A total of 379 tests (0.12%) were classified as having false positive results, yielding an overall specificity of 99.9%. Despite the low frequency of several disorders, the positive predictive value of the overall MS/MS screening was found to be 26%, reflecting high diagnostic specificity of the method. Diagnostic sensitivity of extended screening for the different groups of disorders was 100%. Eight cases of maternal disorders [three glutaric aciduria type I, one carnitine transporter defect, and four 3-methylcrotonyl coenzyme A (CoA) carboxylase deficiency] were also detected through newborn screening.

CONCLUSIONS

Our data support the advantage of a centralised laboratory for screening an elevated number of samples and making decisions if relying on a clinical network able to provide fast treatment and a good outcome in the screened cases.

Biologic therapy and pregnancy. A systematic literature review

AIM

To review available data regarding the safety of biological therapies during pregnancy, focusing on agents used in rheumatology.

METHODS

A systematic literature search was carried out to identify all studies with human data on fetal and/or child outcomes following exposure to biologic agents during pregnancy.

RESULTS

A total of 65 publications out of 745 identified references were included in the review.

CONCLUSIONS

Experience with pregnancy exposure to anti-TNF agents has been slowly accumulating. Although the numbers are small and with few controlled studies the reviewed data suggest that the overall risk of TNF antagonists is relatively low and benefits may outweigh the risks of drug exposure to the fetus. Information on other biologic agents is still very limited. Large controlled studies with longer follow-up periods will be necessary before firm conclusions about the safety of biologics du-ring conception and pregnancy can be drawn.

[Portuguese recommendations on "How to diagnose, monitor, and treat undifferentiated peripheral arthritis": systematic review of the literature and the experts' opinion]

OBJECTIVE

The 3E (Evidence, Expertise, Exchange) Initiative is a multinational effort of rheumatologists aimed at developing evidence-based recommendations addressing specific questions relevant to clinical practice. The objective of the Portuguese contribution for the 3E Initiative was to develop evidence-based recommendations on how to investigate, follow-up and treat undifferentiated peripheral inflammatory arthritis (UPIA) adapted to local reality and develop additional recommendations considered relevant in the national context.

METHODS

An international scientific committee from 17 countries selected a set of questions concerning the diagnosis and monitoring of UPIA using a Delphi procedure. Evidence-based answers to each question were sought by a systematic literature search, performed in Medline, Embase, the Cochrane Library and ACR/EULAR 2007-2009 meeting abstracts. Relevant articles were reviewed for quality assessment, data extraction and synthesis. In a national meeting, a panel of 63 Portuguese rheumatologists used the evidence which was gathered to develop recommendations, and filled the gaps in the evidence with their expert opinion. Finally, national recommendations were formulated and agreement among the participants was assessed.

RESULTS

A total of 54754 references were identified, of which 267 were systematically reviewed. Thirteen national key recommendations about the investigation, follow-up and treatment of UPIA were formulated. One recommendation addressed differential diagnosis and investigations prior to the established operational diagnosis of UPIA, eight recommendations were related to the diagnostic and prognostic value of clinical and laboratory assessments in established UPIA (history and physical examination, acute phase reactants, serologies, autoantibodies, radiographs, magnetic resonance imaging and ultrasound, genetic markers and synovial biopsy), one recommendation highlighted predictors of persistence (chronicity), one addressed monitoring of clinical disease activity in UPIA, one aimed to find an useful method/score to predict a definitive diagnosis and the last one was related to treatment.

CONCLUSION

Portuguese evidence-based recommendations for the management of UPIA in everyday practice were developed. Their dissemination and implementation in daily clinical practice should help to improve practice uniformity and optimize the management of UPIA patients.

Recurrent Focal myositis: a rare inflammatory myopathy

Focal myositis is an acute and localized muscle inflammation of unknown aetiology. The clinical diagnosis is often difficult to obtain, since it can be confused with infections, vascular thrombosis or muscle tumours such as sarcomas. This leads to a significant delay in the diagnosis, resulting in the administration of inappropriate and potentially harmful treatments.  We report here a case of recurrent focal myositis in a woman where the diagnosis was only obtained after 6 years, despite multiple hospital admissions. This case reinforces the importance of clinical knowledge and experience to tackle challenging medical scenarios.

Mortality and functional impairment after hip fracture - a prospective study in a Portuguese population

OBJECTIVES

Osteoporotic hip fractures (HF) are a major cause of morbidity and mortality with increasing familial, social and economic repercussions. The objectives of this paper were to evaluate the status vitae at 6 and 12 months of a cohort of patients with an osteoporotic HF and the risk factors for 12-month mortality as well as to evaluate the functional outcome and the overall health perception of these patients.

PATIENTS AND METHODS

We conducted a 12-month follow-up evaluation of a cohort of 184 patients older than 65 years admitted to our centre with a non-pathological osteoporotic HF from January 1st to December 31st 2007. Baseline data collection was performed in the first 72 hours after admission and, 12 months later, a second evaluation was conducted, by telephone in order to ascertain their status vitae and functional status. The magnitude of sex--specific, age-adjusted associations between potential prognostic factors and mortality was estimated using hazard ratios (HR) and respective 95% confidence intervals (95%CI), calculated using Cox's proportional hazards model.

RESULTS

It was possible to ascertain the status vitae in 164 (89.1%) patients. Overall 12-months mortality was 26.8% (48.3% in males and 22.2% in females). Mortality was higher in patients that became bedridden, were unable to walk again, were admitted to a hospital during the follow-up for any cause and who became dependent in their daily living activities. After discharge, physical therapy and ability to walk again were associated with a lower risk of death. Most of the patients reported a decline of their overall health-related quality of life. More than 75% of patients became totally dependent after HF.

CONCLUSION

This study reinforces the HF poor outcome. Twelve-month mortality rates were similar to the estimates obtained in other studies, although the 6-month's mortality was higher. Physical deterioration and loss of independence in activities of daily living were evident in this study and constituted major factors for low self-esteem and deterioration of quality of life. Our findings may constitute an evidence for action in this particular population, with an active search for means to improve the outcome of HF in these patients.