Outcomes of lowered newborn screening thresholds for congenital hypothyroidism

BACKGROUND

Newborn screening (NBS) has largely eliminated the physical and neurodevelopmental effects of untreated congenital hypothyroidism (CH). Many countries, including Australia, have progressively lowered NBS bloodspot thyroid-stimulating hormone (b-TSH) thresholds. The impact of these changes is still unclear.

OBJECTIVES

To evaluate the performance of CH NBS following the reduction of b-TSH thresholds in New South Wales (NSW) and the Australian Capital Territory (ACT), Australia, from 15 to 8 mIU/L, and to determine the clinical outcomes of cases detected by these thresholds.

METHODS

NBS data of 346 849 infants born in NSW/ACT, Australia from 1 November, 2016-1 March, 2020 inclusive were analysed. A clinical audit was conducted on infants with a preliminary diagnosis of CH born between 1 January, 2016-1 December, 2020 inclusive.

RESULTS

The lowered b-TSH threshold (≥8 mIU/L, ~99.5th centile) detected 1668 infants (0.48%), representing an eight-fold increase in recall rate, of whom 212 of 1668 (12.7%) commenced thyroxine treatment. Of these 212 infants, 62 (29.2%) (including eight cases with a preliminary diagnosis of thyroid dysgenesis) had an initial b-TSH 8-14.9 mIU/L. The positive predictive value for a preliminary diagnosis of CH decreased from 74.3% to 12.8% with the lowered threshold. Proportionally, more pre-term infants received a preliminary CH diagnosis on screening with the lower threshold (16.1% of 62) than with the higher threshold (8.0% of 150).

CONCLUSION

Clinically relevant CH was detected using the lowered threshold, albeit at the cost of an eight-fold increase in recall rate. Further clinical and economic studies are required to determine whether benefits of lowered screening thresholds outweigh potential harms from false-positive results on infants, their families and NBS programs.

Clinical survey of current practice regarding treatment of children with borderline thyroid abnormalities

AIM

Recently, there has been debate about reducing newborn screening (NBS) thyroid-stimulating hormone (TSH) cut-offs to identify children with mild, but potentially clinically significant, thyroid deficiency. Once identified by NBS, these children will be referred to paediatric endocrinologists for further testing and possible treatment; however, variation in current clinical practice is not known. The aim of this study is to survey Paediatric Endocrinologists in Australia and New Zealand to gain insight into clinical practice for the treatment of mild thyroid deficiency.

METHODS

A piloted questionnaire was sent to members of the Australasian Paediatric Endocrinologist Group. The survey asked the Australasian Paediatric Endocrinologist Group members about the investigations performed, treatment and follow-up for infants with different confirmatory serum TSH levels.

RESULTS

There were 42 completed surveys, a response rate of 34%. When presented with four case studies, 7% of clinicians would treat a child with confirmatory serum TSH of 8.7 mU/L with thyroxine, 69% would treat a child with confirmatory serum TSH 21.4 mU/L, 76% would treat a child with confirmatory serum TSH 24.3 mU/L and 95% would treat a child with confirmatory serum TSH 44.7 mU/L.

CONCLUSION

This contemporary survey of clinicians regarding the treatment of mild thyroid deficiency in children has shown that clinical practice varies extensively. International and national guidelines on the treatment of congenital hypothyroidism should be updated to incorporate new evidence and ensure consistency across clinical practice.

Universal Subsidized Continuous Glucose Monitoring Funding for Young People With Type 1 Diabetes: Uptake and Outcomes Over 2 Years, a Population-Based Study

OBJECTIVE

Continuous glucose monitoring (CGM) is increasingly used in type 1 diabetes management; however, funding models vary. This study determined the uptake rate and glycemic outcomes following a change in national health policy to introduce universal subsidized CGM funding for people with type 1 diabetes aged <21 years.

RESEARCH DESIGN AND METHODS

Longitudinal data from 12 months before the subsidy until 24 months after were analyzed. Measures and outcomes included age, diabetes duration, HbA1c, episodes of diabetic ketoacidosis and severe hypoglycemia, insulin regimen, CGM uptake, and percentage CGM use. Two data sources were used: the Australasian Diabetes Database Network (ADDN) registry (a prospective diabetes database) and the National Diabetes Service Scheme (NDSS) registry that includes almost all individuals with type 1 diabetes nationally.

RESULTS

CGM uptake increased from 5% presubsidy to 79% after 2 years. After CGM introduction, the odds ratio (OR) of achieving the HbA1c target of <7.0% improved at 12 months (OR 2.5, P < 0.001) and was maintained at 24 months (OR 2.3, P < 0.001). The OR for suboptimal glycemic control (HbA1c ≥9.0%) decreased to 0.34 (P < 0.001) at 24 months. Of CGM users, 65% used CGM >75% of time, and had a lower HbA1c at 24 months compared with those with usage <25% (7.8 ± 1.3% vs. 8.6 ± 1.8%, respectively, P < 0.001). Diabetic ketoacidosis was also reduced in this group (incidence rate ratio 0.49, 95% CI 0.33-0.74, P < 0.001).

CONCLUSIONS

Following the national subsidy, CGM use was high and associated with sustained improvement in glycemic control. This information will inform economic analyses and future policy and serve as a model of evaluation diabetes technologies.

Calcaneotibial screws for immobilisation of the tarsocrural joint of dogs in extension: effect of the angle of screw placement on the force to failure in a canine cadaveric model

AIMS

To compare the force to failure under axial loading of a calcaneotibial screw placed approximately perpendicular to the tibia with that of a screw placed perpendicular to the calcaneus, when used to immobilise the tarsus in an ex vivo canine model.

METHODS

Twelve pairs of cadaveric hindlimbs from large breed dogs, without orthopaedic or soft tissue disease, were prepared by transecting the limb at the level of the stifle and stripping the limbs of all musculature from the stifle to mid-metatarsus, including removal of the common calcaneal tendon from all limbs. The limbs in each pair were randomly assigned to receive a calcaneotibial screw placed perpendicular to the long axis of either the calcaneus (C group) or the tibia (T group) with the tarsus in full extension. The distal limb was potted in resin and the proximal tibia was pinned to allow biomechanical testing in compressive loading. Testing was performed to apply an axial load using a material testing machine in a proximodistal direction through the tibia, advancing at a rate of 10 mm/second. The force to failure was recorded in kN and compared between groups.

RESULTS

The median force to failure of the C group was 0.86 (min 0.50; max 1.64) kN which was higher than the T group which had a median force to failure of 0.74 (min 0.26, max1.05) kN (p = 0.004). All modes of failure were by screw pull-out.

CONCLUSIONS

A calcaneotibial screw placed at an angle approximately perpendicular to the long axis of the calcaneus, has a higher force to failure under axial loading than a calcaneotibial screw that is placed at an angle approximately perpendicular to the tibia, in a canine cadaveric model.

CLINICAL RELEVANCE

A temporary calcaneotibial screw is a common method of immobilising the tarsus in extension to protect primary repair of a common calcaneal tendon injury. Placing a calcaneotibial screw perpendicular to the calcaneus may be a more reliable option for immobilisation of the tarsus to protect a common calcaneal tendon repair compared to screws placed perpendicular to the tibia. However extrapolation of these results into a clinical setting requires caution.

Association of elevated neonatal thyroid-stimulating hormone levels with school performance and stimulant prescription for attention deficit hyperactivity disorder in childhood

Untreated severe newborn thyroid deficiency causes neurocognitive impairment; however, the impact of mild thyroid deficiency is not known. This study aimed to examine whether mildly elevated neonatal thyroid-stimulating hormone (TSH) levels are associated with poor school performance or stimulant prescription for attention deficit hyperactivity disorder (ADHD). This record-linkage study included 232,790 term-born infants in Australia with a TSH level below newborn screening threshold (< 15 mIU/L). Among our cohort, as TSH levels increased, the proportion of infants born low birthweight via caesarean section and with disadvantaged socioeconomic status increased. Multivariable logistic regression analysis showed that, compared with infants with 'normal' neonatal TSH level (< 5 mIU/L), those with neonatal TSH 10-15 mIU/L had an increased risk of being exempt from school testing (aOR 1.63 (95% CI 1.06-2.69)) or prescribed a stimulant for ADHD (aOR 1.57 (95% CI 1.10-2.24)), adjusted for perinatal and sociodemographic factors. Among a nested analysis of 460 sibling pairs, siblings with 'mildly elevated' TSH levels were more likely to be exempt from school tests compared with siblings with normal TSH levels (aOR 2.53, 95% CI 1.01-6.33).Conclusion: In this population cohort and sibling analysis, mildly elevated neonatal TSH levels were associated with being exempt from school testing due to significant or complex disability. What is Known: • Newborn screening for severe thyroid hormone deficiency has virtually eliminated congenital hypothyroidism-associated intellectual disability in developed countries. • The impact of mild thyroid hormone deficiency in infants is unclear. What is New: • Children with a mildly elevated neonatal TSH level below current newborn screening cut-offs have an increased likelihood of being exempt from school testing due to significant or complex disability compared with siblings and peers. This study includes a population-based and nested sibling analysis.

Kinetics of Plasma Cell-Free DNA and Creatine Kinase in a Canine Model of Tissue Injury

Background

Cell‐free DNA (cfDNA) comprises short, double‐stranded circulating DNA sequences released from damaged cells. In people, cfDNA concentrations correlate well with disease severity and tissue damage. No reports are available regarding cfDNA kinetics in dogs.

Objectives/Hypothesis

Cell‐free DNA will have a short biological half‐life and would be able to stratify mild, moderate, and severe tissue injury. Our study aims were to determine the kinetics and biological half‐life of cfDNA and to contrast them with those of creatine kinase (CK).

Animals

Three groups of 10 dogs undergoing open ovariohysterectomy, surgery for cranial cruciate ligament rupture (CCLR), or hemilaminectomy.

Methods

Plasma for cfDNA and CK analysis was collected at admission, at induction of anesthesia, postsurgery (time 0) and at 6, 12, 24, 36, 48, 60, and 72 hours after surgery.

Results

The biological half‐life of plasma cfDNA and CK were 5.64 hours (95% confidence interval [CI 95], 4.36–7.98 hours) and 28.7 hours (CI95, 25.3–33.3 hours), respectively. In the hemilaminectomy group, cfDNA concentrations differed significantly from admission at 6–12 hours after surgery. Creatine kinase activity differed among the surgical groups and reached a peak 6 hours after surgery. In the ovariohysterectomy and CCLR groups, plasma CK activity 72 hours after surgery did not differ from admission activity of the ovariohysterectomy group. In contrast, in the hemilaminectomy group, plasma CK activity after 72 hours did not return to the ovariohysterectomy group admission activity.

Conclusions and Clinical Importance

Plasma CK activity has a longer biological half‐life than previously thought. In contrast to plasma CK activity, cfDNA has a short half‐life and could be a useful marker for peracute severe tissue injury.

The Diagnosis and Management of Lipodystrophy Syndromes: A Multi-Society Practice Guideline

OBJECTIVE

Lipodystrophy syndromes are extremely rare disorders of deficient body fat associated with potentially serious metabolic complications, including diabetes, hypertriglyceridemia, and steatohepatitis. Due to their rarity, most clinicians are not familiar with their diagnosis and management. This practice guideline summarizes the diagnosis and management of lipodystrophy syndromes not associated with HIV or injectable drugs.

PARTICIPANTS

Seventeen participants were nominated by worldwide endocrine societies or selected by the committee as content experts. Funding was via an unrestricted educational grant from Astra Zeneca to the Pediatric Endocrine Society. Meetings were not open to the general public.

EVIDENCE

A literature review was conducted by the committee. Recommendations of the committee were graded using the system of the American Heart Association. Expert opinion was used when published data were unavailable or scarce.

CONSENSUS PROCESS

The guideline was drafted by committee members and reviewed, revised, and approved by the entire committee during group meetings. Contributing societies reviewed the document and provided approval.

CONCLUSIONS

Lipodystrophy syndromes are heterogeneous and are diagnosed by clinical phenotype, supplemented by genetic testing in certain forms. Patients with most lipodystrophy syndromes should be screened for diabetes, dyslipidemia, and liver, kidney, and heart disease annually. Diet is essential for the management of metabolic complications of lipodystrophy. Metreleptin therapy is effective for metabolic complications in hypoleptinemic patients with generalized lipodystrophy and selected patients with partial lipodystrophy. Other treatments not specific for lipodystrophy may be helpful as well (eg, metformin for diabetes, and statins or fibrates for hyperlipidemia). Oral estrogens are contraindicated.

Association between borderline neonatal thyroid-stimulating hormone concentrations and educational and developmental outcomes: a population-based record-linkage study

BACKGROUND

Congenital hypothyroidism causes intellectual delay unless identified and effectively treated soon after birth. Newborn screening has almost eliminated intellectual disability associated with congenital hypothyroidism. However, clinical uncertainty remains about infants with thyroid-stimulating hormone (TSH) concentrations less than the newborn screening cutoffs. We assessed the association between neonatal TSH concentrations and educational and developmental outcomes.

METHODS

We did a population-based record-linkage study of all liveborn infants undergoing newborn screening from 1994 to 2008 in New South Wales, Australia, with assessments of childhood development or school performance. Very-low-birthweight babies (<1500 g) were excluded. Developmental and educational outcomes were obtained and these were linked to individual records by the New South Wales Centre for Health Record Linkage. The primary educational outcome was the proportion of students with National Assessment Program Literacy and Numeracy (NAPLAN) results lower than the national minimum standard in reading or numeracy measured at all ages, and the primary developmental outcome was the proportion of children who were classified as being developmentally high risk (vulnerable in two or more of the five developmental domains assessed by the Australian Early Development Census) at age 4-6 years. The proportions of infants with each outcome were calculated per percentile (0-100) of TSH concentration. Multivariable logistic regression was used to account for potential confounding by maternal and fetal variables known to affect neonatal TSH concentrations or neurodevelopmental outcomes.

FINDINGS

503 706 infants had a neonatal TSH result that linked to a developmental or educational outcome. 149 569 infants born between 2002 and 2008 were linked to an Australian Early Development Census developmental outcome and 354 137 were linked to a NAPLAN educational outcome. Median follow-up for educational outcome was 10 years (IQR 8-12) and for developmental outcome was 5 years (5-6). 5·5% (14 137 of 257 752) of infants scored less than the national minimum standard for numeracy in percentiles lower than the 75th percentile and this increased with each increase of percentile group to 11·3% (15 of 133) of infants with a TSH concentration between the 99·90th and 99·95th percentile. Infants with a neonatal TSH concentration in the 99·95th percentile or higher (above newborn screening cutoff) and likely to have diagnosed and treated congenital hypothyroidism had similar results to infants with a TSH concentration lower than the 75th percentile for both educational and developmental outcomes. Infants with a neonatal TSH concentration between the 99·5th and 99·9th percentile were more likely to have special needs (adjusted odds ratio [aOR] 1·68, 95% CI 1·23-2·30), poor numeracy performance (aOR 1·57, 1·29-1·90), and developmentally high risk (aOR 1·52, 1·20-1·93).

INTERPRETATION

We found an association between neonatal TSH concentrations lower than the present newborn screening thresholds and poor educational and developmental outcomes. This association needs further investigation to assess whether assessment and treatment of these infants might improve their long-term cognitive outcomes.

FUNDING

Australian National Health and Medical Research.

Factors that influence the childbearing intentions of Canadian men

BACKGROUND

The role of men in the childbearing decision process and the factors that influence men's childbearing intentions have been relatively unexplored in the literature. This study aimed to describe the factors that strongly influence the childbearing intentions of men and to describe differences in these factors according to men's age group.

METHODS

A telephone survey (response rate 84%) was conducted with 495 men between the ages of 20 and 45 living in an urban setting who, at the time of contact, did not have biological children. Men were asked about what factors strongly influence their intention to have children. Univariable and multivariable logistic regressions were conducted to determine if these factors were significantly associated with age.

RESULTS

Of those sampled, 86% of men reported that at some point in the future they planned to become a parent. The factors that men considered to be most influential in their childbearing intentions were: the need to be financially secure, their partner's interest/desire to have children, their partner's suitability to be a parent and their personal interest/desire to have children. Men who were 35–45 years old had lower odds of stating that financial security (crude OR: 0.32, 95% CI: 0.18–0.54) and partner's interest in having children (crude OR: 0.57, 95% CI: 0.33–0.99) were very influential, but had higher odds of stating that their biological clock (crude OR: 4.37, 95% CI: 1.78–10.76) was very influential in their childbearing intentions than men in the 20–24 year age group.

CONCLUSIONS

The factors that influence men's intentions about when to become a parent may change with age. Understanding what influences men to have children, and what they understand about reproductive health is important for education, program and policy development.

Intrathyroid dermoid cyst presenting as a unilateral "Cold" nodule

A dermoid cyst arising in the left lobe of the thyroid gland in a 5-year-old boy was managed with a left hemi-thyroidectomy. While congenital lesions feature frequently in the differential diagnosis of childhood neck masses, dermoid cysts presenting as a unilateral neck mass are rare. When found within the thyroid, their pathogenesis may be explained by a disruption of normal thyroid development. Excision appears the treatment of choice.

Education improves colorectal cancer screening by flexible sigmoidoscopy in an inner city population

OBJECTIVE

The District of Columbia General Hospital has a flexible sigmoidoscopy (FS) colorectal cancer screening program. We noted that this program was underused. The aim of this study was to determine whether education could improve use of a flexible sigmoidoscopy screening program in an inner city population.

METHODS

Patients undergoing screening FS 5 months before our educational initiative were compared to patients undergoing screening FS 5 months after implementation. A 1-month period was allowed for implementation. Procedure logs and GI charts were reviewed.

RESULTS

A total of 121 patients underwent FS screening during our study period. Of the patients, 97% were African-American; 58% were female; and the average age was 61 yr. A total of 50 patients underwent FS in the pre-education group, and 71 patients underwent FS after implementation of our educational initiative.

CONCLUSIONS

Education resulted in a 42% increase in FS screening in this inner city, predominantly African-American population. Larger scale educational initiatives should be conducted to determine whether these benefits can persist and can be improved upon.

Biodegradation of fluoranthene by soil fungi

A selection of 39 strains of micromycetes known as good degraders of polychlorinated aromatic compounds, mostly isolated from soil and belonging to various taxonomic groups, have been investigated for fluoranthene degradation. Toxicity assays, first evaluated on solid medium MEA, have not shown any toxicity of fluoranthene (1-100 mg.L-1) towards fungi. Whereas, consumption assays on a solid synthetic medium showed a toxicity at 100 mg.L-1. The degradation of fluoranthene (10 mg.L-1) was then investigated in a liquid synthetic medium for 4 days and evaluated by HPLC. Among the 39 strains tested, 18 degraded fluoranthene at 60% or more. Zygomycetes appeared to be the most efficient group (mean degradation: 90%). Among 18 performant strains, 10 had not yet been reported in the literature: Sporormiella australis, Cryptococcus albidus, Cicinobolus cesatii, Pestalotia palmarum, beauveria alba, Aspergillus terreus. Cunninghamella blakesleeana, C. echinulata, Mortierella ramanniana and Rhizopus arrhizus. Fluoranthene adsorption on fungi was very low for the strains which degraded well fluoranthene (mean adsorption: 4%). Whereas, some strains adsorbed it much more such as Colletotrichum dematium (47%) and Penicillium italicum (43%).

Public-private partnership organizations in health care: cooperative strategies and models

Value-adding partnerships have emerged as a preferred strategy of private health care providers to achieve high-quality, low-cost provider status. This same strategy can be applied by public sector providers through the creation of public-private partnership organizations (3POs). Strategies to build 3POs between local governments and their medical communities currently under development are outlined. The conceptual and practical aspects of implementing 3POs are presented.

Scabies outbreak in an extended care unit--a positive outcome

A recent outbreak of scabies occurred in an extended care unit attached to an acute care hospital. Seventy-eight residents and over 100 staff and family members were treated at a cost of more than $20,000. The protocol in use at that time was found to be inadequate for an outbreak situation because it was based on the assumption that all staff would have previous experience of this type of problem. Close liaison with the head nurse of the affected unit, the occupational health and safety department, the medical microbiologist and the infection control department has resulted in the development of a procedure that reflects all of the concerns that were raised during the outbreak. In addition, a policy was formulated to cover problems associated with contacting medical personnel in a timely manner. This outbreak has resulted in positive changes in procedures as well as improved communication in a wide variety of departments within the hospital.

Familiarity, proximity and self-injurious behaviors

This paper introduces familiarity and proximity of direct-care staff as possible contributors to the etiology of self-injurious behaviors. Analysis suggests that research workers consider these two variables when evaluating the etiology of such behaviors with specific reference to positive and negative reinforcement paradigms.