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MASS SCREENING FOR CRETINISM
356 and ideally these should be worked through in supervised classes. What emerges is that most patients can exercise much more than was formerly thought possible or advisable, and they can therefore live a fuller and Much remains to be learned more enjoyable life. about rehabilitation, an aspect of medical care not less important than diagnosis or therapy. The patient needs advice which is both well-founded and practical; and in cardiac rehabilitation the R.C.P./B.C.S. report sets new standards. MASS SCREENING FOR CRETINISM
NEONATAL feeding difficulties confront the pædiatrician daily. Common causes include birth shock, infection, and jaundice; but, along with constipation and respiratory troubles, feeding difficulties may be the presenting clinical feature of hypothyroidism. The classic cretinous facies is seen in only a quarter of cases diagnosed before three months, the proportion increasing with increasing delay in replacement
therapy.1 Cretinism is a rare cause of mental retardation but treatable one. It can be easily missed until later in the first year of life, and early replacement therapy In a Great Ormond is unfortunately essential. Street series,l 14 out of 19 children diagnosed and treated before three months of age had I.Q.s over 90, whereas only about a third of those treated later reached this level. These findings are borne out by Klein and his co-workers.2 Eayrs3 has shown that thyroxine is essential for brain maturation in prenatal and early postnatal life and only small amounts of thyroxine cross the human placental barrier. In the neonate there is acute release of thyroidstimulating hormone (T.s.H.) during the first hours of life, causing an increase in all indices of thyroid function.4 Serum protein-bound iodine, butamolextractable thyroxine, 131I-triiodothyronine uptake in erythrocytes or resin (T3 tests), dialysable thyroxine, and 131I uptake in the thyroid gland should all be raised-i.e., the normal infant is hyperthyroid. Rogowski and co-workers5 report that the rise in dialysable thyroxine parallels the rise in total thyroxine; therefore the increase in plasma-thyroxine is not caused by an increase in thyroxine-binding proteins, 6 as has been suggested. Until lately only small series of infants have been studied, because of the quantity of blood needed for macromethod testing of thyroid function. But now micromethods permit testing of large numbers. The series of Dussault et al.,’ in Canada, is the largest so a
far. 47 000 newborns have been studied by a cheap, reliable micromethod using the T4 test, which has revealed an incidence of hypothyroidism of 1 in 7000. In a smaller series from the U.S.A., Klein and others8 used a T.S.H. screening procedure and found an incid1. Raiti, S., Newns, G. H. Archs Dis. Childh. 1971, 46, 692. Klein, A. H., Meltzer, S., Kenny, F. M. J. Pediat. 1972, 81, 912. Eayrs, J. T. Br. med. Bull. 1960, 16, 122. Utiger, R. D., Wilber, J. F., Cornbathy, M., Harm, J. P., Mack, R. E. J. clin. Invest. 1968, 47, 97. 5. Rogowski, P., Siersboek-Nielsen, K., Hansen, J. M. Acta pœdiat. scand. 1974, 63, 201. 6. Chadd, M. A., Gray, O. P., Davies, D. F. Archs Dis. Childh. 1970, 45, 374. 2. 3. 4.
7.
8.
Dussault, J. H., Coulombe, P., Laberge, C., Letatle, J., Guyda, M., Khoury, K. Pediatrics, 1975, 86, 670. Klein, A. H., Agustin, A. V., Foley, T. P. Lancet, 1974, ii, 77.
of 1 in 8500, which they compare with the incidof phenylketonuria in the United States-1 in 14 300. These figures present a serious case for routine
ence
ence
screening. CANCER BY COUNTY MAps of cancer distribution are a fascinating source of clues-and of false trails-in the search for aetiological factors. In the U.S.A. the variations from State to State are striking, and now the magnification has been stepped up with a county-by-county survey.2 The basic data were derived by the epidemiology branch of the National Cancer Institute from all the death certificates of the 48 contiguous States in which cancer was listed as the cause of death. The average annual age-adjusted mortality-rates for the period 1950-69 were calculated for individual counties or State economic areas using the total U.S. population of 1960 as standard, and the maps were produced by a special automated cartography system. They deal with cancer in U.S. Whites, since for non-Whites basic data on cancer mortality and populations at risk were too scanty. For cancers of salivary glands and pancreas, of the nasal system, of the nervous system, and of connective tissue no geographic patterns are discernible. Rates for ovary, testis, and bladder in females are high in the rural north and low in the rural south. Males in the North-East and in some urban Great Lakes centres prone to cancers of gastrointestinal tract, œsophagus, larynx, and bladder, while the rates in southern
are
generally low. The northdistinguished by high rates for lymphomas (in females), multiple myeloma, leukaemia, and cancers of stomach, kidney, and prostate, while southern females are susceptible to cancers of eye, bone, lip, mouth, throat, oesophagus, and cervix uteri: they share with the southern male high rates and central males central States are
are
for melanoma and other skin cancers. Liver cancer is irregularly distributed, with high rates along the Gulf Coast from Texas to Louisiana and in parts of
Appalachia. Some of the factors behind these irregularities emerge when individual counties are compared. Thus stomach cancer seems to be influenced by ethnic factors: the high mortality in certain north-central areas corresponds to immigration from parts of Europe with high stomach-cancer rates; but why should colon cancer be frequent in both sexes in S.E. Nebraska, and why is lung cancer so frequent in some rural and port areas of the south ? Industrial exposure must surely be responsible for the monstrous bladder-cancer rates in New Jersey, especially in Salem county, where a quarter of the workforce is in chemical or allied industries. Almost all these maps show areas of high and low occurrence of some or other cancer, and if one of the functions of maps is direction-finding then this atlas is full of pointers. 1. 2.
Burbank, F. Patterns of Cancer Mortality in the United States 1950-1967. Natn. Cancer Inst. Monogr. no. 33, 1971. Mason, T. J., McKay, F. W., Hoover, R., Blot, W. J., Fraumeni, J. F. Atlas of Cancer Mortality for U.S. Counties 1950-1969. Department of Health, Education and Welfare publication no. (NIH) 75.480. National Institutes of Health, Washington, D.C., 1975.
NEONATAL feeding difficulties confront the pædiatrician daily. Common causes include birth shock, infection, and jaundice; but, along with constipation and respiratory troubles, feeding difficulties may be the presenting clinical feature of hypothyroidism. The classic cretinous facies is seen in only a quarter of cases diagnosed before three months, the proportion increasing with increasing delay in replacement
therapy.1 Cretinism is a rare cause of mental retardation but treatable one. It can be easily missed until later in the first year of life, and early replacement therapy In a Great Ormond is unfortunately essential. Street series,l 14 out of 19 children diagnosed and treated before three months of age had I.Q.s over 90, whereas only about a third of those treated later reached this level. These findings are borne out by Klein and his co-workers.2 Eayrs3 has shown that thyroxine is essential for brain maturation in prenatal and early postnatal life and only small amounts of thyroxine cross the human placental barrier. In the neonate there is acute release of thyroidstimulating hormone (T.s.H.) during the first hours of life, causing an increase in all indices of thyroid function.4 Serum protein-bound iodine, butamolextractable thyroxine, 131I-triiodothyronine uptake in erythrocytes or resin (T3 tests), dialysable thyroxine, and 131I uptake in the thyroid gland should all be raised-i.e., the normal infant is hyperthyroid. Rogowski and co-workers5 report that the rise in dialysable thyroxine parallels the rise in total thyroxine; therefore the increase in plasma-thyroxine is not caused by an increase in thyroxine-binding proteins, 6 as has been suggested. Until lately only small series of infants have been studied, because of the quantity of blood needed for macromethod testing of thyroid function. But now micromethods permit testing of large numbers. The series of Dussault et al.,’ in Canada, is the largest so a
far. 47 000 newborns have been studied by a cheap, reliable micromethod using the T4 test, which has revealed an incidence of hypothyroidism of 1 in 7000. In a smaller series from the U.S.A., Klein and others8 used a T.S.H. screening procedure and found an incid1. Raiti, S., Newns, G. H. Archs Dis. Childh. 1971, 46, 692. Klein, A. H., Meltzer, S., Kenny, F. M. J. Pediat. 1972, 81, 912. Eayrs, J. T. Br. med. Bull. 1960, 16, 122. Utiger, R. D., Wilber, J. F., Cornbathy, M., Harm, J. P., Mack, R. E. J. clin. Invest. 1968, 47, 97. 5. Rogowski, P., Siersboek-Nielsen, K., Hansen, J. M. Acta pœdiat. scand. 1974, 63, 201. 6. Chadd, M. A., Gray, O. P., Davies, D. F. Archs Dis. Childh. 1970, 45, 374. 2. 3. 4.
7.
8.
Dussault, J. H., Coulombe, P., Laberge, C., Letatle, J., Guyda, M., Khoury, K. Pediatrics, 1975, 86, 670. Klein, A. H., Agustin, A. V., Foley, T. P. Lancet, 1974, ii, 77.
of 1 in 8500, which they compare with the incidof phenylketonuria in the United States-1 in 14 300. These figures present a serious case for routine
ence
ence
screening. CANCER BY COUNTY MAps of cancer distribution are a fascinating source of clues-and of false trails-in the search for aetiological factors. In the U.S.A. the variations from State to State are striking, and now the magnification has been stepped up with a county-by-county survey.2 The basic data were derived by the epidemiology branch of the National Cancer Institute from all the death certificates of the 48 contiguous States in which cancer was listed as the cause of death. The average annual age-adjusted mortality-rates for the period 1950-69 were calculated for individual counties or State economic areas using the total U.S. population of 1960 as standard, and the maps were produced by a special automated cartography system. They deal with cancer in U.S. Whites, since for non-Whites basic data on cancer mortality and populations at risk were too scanty. For cancers of salivary glands and pancreas, of the nasal system, of the nervous system, and of connective tissue no geographic patterns are discernible. Rates for ovary, testis, and bladder in females are high in the rural north and low in the rural south. Males in the North-East and in some urban Great Lakes centres prone to cancers of gastrointestinal tract, œsophagus, larynx, and bladder, while the rates in southern
are
generally low. The northdistinguished by high rates for lymphomas (in females), multiple myeloma, leukaemia, and cancers of stomach, kidney, and prostate, while southern females are susceptible to cancers of eye, bone, lip, mouth, throat, oesophagus, and cervix uteri: they share with the southern male high rates and central males central States are
are
for melanoma and other skin cancers. Liver cancer is irregularly distributed, with high rates along the Gulf Coast from Texas to Louisiana and in parts of
Appalachia. Some of the factors behind these irregularities emerge when individual counties are compared. Thus stomach cancer seems to be influenced by ethnic factors: the high mortality in certain north-central areas corresponds to immigration from parts of Europe with high stomach-cancer rates; but why should colon cancer be frequent in both sexes in S.E. Nebraska, and why is lung cancer so frequent in some rural and port areas of the south ? Industrial exposure must surely be responsible for the monstrous bladder-cancer rates in New Jersey, especially in Salem county, where a quarter of the workforce is in chemical or allied industries. Almost all these maps show areas of high and low occurrence of some or other cancer, and if one of the functions of maps is direction-finding then this atlas is full of pointers. 1. 2.
Burbank, F. Patterns of Cancer Mortality in the United States 1950-1967. Natn. Cancer Inst. Monogr. no. 33, 1971. Mason, T. J., McKay, F. W., Hoover, R., Blot, W. J., Fraumeni, J. F. Atlas of Cancer Mortality for U.S. Counties 1950-1969. Department of Health, Education and Welfare publication no. (NIH) 75.480. National Institutes of Health, Washington, D.C., 1975.