Congenital thyrotoxicosis in premature infants

OBJECTIVES Graves' disease (GD) complicates 0.1% to 0.2% of pregnancies, but congenital thyrotoxicosis is rare occurring in one in 70 of these pregnancies independent of maternal disease status. Antenatal prediction of affected infants is imprecise; however, maternal history, coupled with a high maternal serum TSH receptor binding immunoglobulin index (TBII) predict adverse neonatal outcome. Mortality is reported to be as high as 25% in affected infants and would therefore be expected to be higher in premature infants. This study illustrates that in sick, premature, extreme low birth weight (ELBW) or intrauterine growth retarded (IUGR) infants, the diagnosis maybe overlooked especially in the absence of antenatal risk assessment and management of thyrotoxicosis in this setting is complex. DESIGN and PATIENTS The records of premature neonates born at the three main maternity units in Brisbane, between January 1996 and July 1998 diagnosed with congenital thyrotoxicosis were reviewed. Data were recorded on gestational age, birth weight (B Wt), maternal thyroid history and current status, and neonatal course. Thyroid function and TBII status was assessed using standard biochemical assays. RESULTS Seven neonates from five pregnancies were identified (four female, three male). Mean gestational age was 30 week (25-36 week) and median B Wt was 1.96 kg (0.50-2.62 kg). Only one mother received formal antenatal counselling by a paediatric endocrine service and had a TBII (54%) measured prior to delivery. Three of five mothers had elevated TBII measured after diagnosis in their offspring (57%, 65%, 83%) and in one mother, a TBII was not performed. All mothers were biochemically euthyroid at delivery. Mean age at diagnosis was 9 days (1-16 days) and mean age at commencement of treatment was 12 days (7-26 days). Two infants received propylthiouracil and five received a combination of carbimazole and propranolol. Pour became biochemically hypothyroid, in three this resolved with cessation of the antithyroid drug (ATD), and one required ongoing T4 supplementation. Only one infant required treatment for cardiac failure and there were no deaths in this cohort. CONCLUSIONS This is a large series of extremely small and premature infants with neonatal thyrotoxicosis. Presentation was nonspecific. The diagnosis was delayed because of low birth weight, prematurity, multiple birth and/or an unrecognized maternal history of Graves' disease. The treatment of neonatal thyrotoxicosis was difficult in these extreme law birth weight infants yet no infant died and significant morbidity was confined to high output cardiac failure in one infant. With antenatal recognition of past or active Graves' disease, assessment of maternal TSH receptor binding immunoglobulin index prior to delivery and postnatal monitoring of cord TSH and venous fT4 and TSH on days 4 and 7 rapid treatment of affected infants may have further reduced neonatal morbidity.

Healthy ageing - Adults with intellectual disabilities: Physical health issues

This report has been prepared by the Ageing Special Interest Research Group of the International Association for the Scientific Study of Intellectual Disabilities (IASSID) in collaboration with the Department of Mental Health and Substance Dependence and the Programme on Ageing and Health, World Health Organization (WHO), Geneva, Switzerland, and all rights are reserved by the above mentioned organization. The document may, however, be freely reviewed, abstracted, reproduced or translated in part, but not for sale or use in conjunction with commercial purposes. It may also be reproduced in full by non-commercial entities for information or for educational purposes with prior permission from WHO/IASSID. The document is likely to be available in other languages also.

Audit and comprehensive health assessment programme in the primary healthcare of adults with intellectual disability: a pilot study

International research has demonstrated significant shortcomings in the health of adults with intellectual disability (ID). Because general practitioners (GPs) are the main providers of primary healthcare for this population, strategies to improve general practice care are an important aspect of rectifying these shortcomings. The present pilot study aimed to determine the effect of various interventions on health maintenance activities and to assess their acceptability to GPs, with a view to informing larger scale studies. The GPs were recruited through an earlier questionnaire-based postal survey. The GPs identified all their adult patients with ID, then obtained consent for participation from three patients randomly selected by the investigators. The GPs completed two self-evaluation forms and case note audits 12 months apart, read a synopsis of the relevant literature provided by the researchers, and completed a comprehensive health assessment (CHA) of their three patients. Forty-five GPs agreed to participate in the CHA programme (CHAP), and 15 completed the project. Thirty-eight patients completed the project. The number of patient-GP dyads who completed the project was too small to demonstrate statistically significant changes in health issues over time. The GPs found that the synopsis of the literature was the best intervention for increasing knowledge and was also the most practical to use in general practice. The CHAP was the intervention that prompted the most action from the GP which would not have been undertaken otherwise. The CHAP appeared to provide a superior review process compared to the other interventions used in the present study. The numbers of health maintenance activities found to be overdue and the number of health issues detected as a result of the process were considerable. The CHAP served as a communication tool and an educative instrument, providing a basis for future studies and strategies to improve the general practice care of adults with ID.

Advances in neurotrauma in Australia 1970-2000

The management of neurotrauma in Australia has been one of the significant public health triumphs during the last 30 years of the 20th century. State and national government agencies act in a coordinated fashion to collect data and to promote research on how to manage neurotrauma patients. Between 1970 and 1995, fatalities from road accidents decreased by 47%. Hospital admissions have decreased by 40% despite a 40% increase in the population and a 120% increase in registered vehicles. Fatalities per 10,000 registered vehicles were 8.05% in 1970 and they fell to 1.84% per vehicles in 1995, while fatalities per 10;000 population were 3 in 1970 falling to 1.11 in 1995. Hospitalization from road crashes decreased 23% between March 1988 and March 1997. Public education has steadily improved, backed by the state public health sources. A uniform code of road safety laws has been adopted, backed by legislation and legal penalties and increasing police enforcement. Clinical care of patients has improved as a result of faster communications, tele-medicine, trauma systems, the CT scanner; intensive care units, and improved monitoring. Patient rehabilitation and counseling are now carried out at units accredited by the Australian Council on Health Care Standards.

A risk-based system to penalize and reward line management for occupational safety and health performance

Penalizing line management for the occurrence of lost time injuries has in some cases had unintended negative consequences. These are discussed. An alternative system is suggested that penalizes line management for accidents where the combination of the probability of recurrence and the maximum reasonable consequences such a recurrence may have exceeds an agreed limit. A reward is given for prompt effective control of the risk to below the agreed risk limit. The reward is smaller than the penalty. High-risk accidents require independent investigation by a safety officer using analytical techniques. Two case examples are given to illustrate the system. Continuous safety improvement is driven by a planned reduction in the agreed risk limit over time and reward for proactive risk assessment and control.

The design of hazard risk assessment matrices for ranking occupational health risks and their application in mining and minerals processing

Two hazard risk assessment matrices for the ranking of occupational health risks are described. The qualitative matrix uses qualitative measures of probability and consequence to determine risk assessment codes for hazard-disease combinations. A walk-through survey of an underground metalliferous mine and concentrator is used to demonstrate how the qualitative matrix can be applied to determine priorities for the control of occupational health hazards. The semi-quantitative matrix uses attributable risk as a quantitative measure of probability and uses qualitative measures of consequence. A practical application of this matrix is the determination of occupational health priorities using existing epidemiological studies. Calculated attributable risks from epidemiological studies of hazard-disease combinations in mining and minerals processing are used as examples. These historic response data do not reflect the risks associated with current exposures. A method using current exposure data, known exposure-response relationships and the semi-quantitative matrix is proposed for more accurate and current risk rankings.

Survivors and victims: A case study of organisational restructuring in the public health sector

This paper examines a process of major organizational restructuring in an Australian hospital within a context of decentralization of health services and relocation of clients, brought about by changes in government policy. The change process differed from the abrupt downsizing often found in the private sector in that the organization initiated significant job losses concomitantly with the development of new facilities around the State, while attempting to deal with employee issues related to downsizing. The paper focuses on the process involved in the downsizing, from the perspective of both the "survivors" and "victims" of the change. It draws on interviews and focus groups with managers, union officials and employees, as well a survey of employees to assess the outcomes and effectiveness of the restructuring process. Using a stakeholder analysis framework, the paper examines the complex issues and perspectives raised by the downsizing process.

Short communication: Extended shifts in ambulance work: influences on health

Shiftwork is a major source of stress for many worker's. This study highlights the role that organizational and psychosocial variables play in alleviating the negative health effects of 10 and 14-h shifts. It examines the direct and mediated effects of coping strategies, social support and control of shifts on work/non-work conflict and subjective health. Participants are 60 ambulance workers, aged 22 to SS years. A structural equation model with good fit demonstrates complex effects of social support from various sources (supervisors, co-workers and family), coping and control on work/non-work conflict and subjective health., Conceptually, the research contributes to the development of a theoretical framework that can assist in explaining how key psychosocial and organizational variables influence the psychological and physical symptoms experienced by shiftworkers. Copyright (C) 2002 John Wiley Sons, Ltd.

Population health, environment and economic development

This paper studies the role of income distribution and technology transfer in the process of economic development. A novel aspect of the model is that the composition of human capital as well as the level affect economic growth. Utilizing an overlapping-generations model in which income distribution changes endogenously, we present an economic explanation for why some countries could not start modern economic growth; why some countries took off but have apparently stopped growing after some time; and why some countries have successfully developed and continue to grow