Epidemiology of insulin dependent diabetes before age 20 in Wisconsin, with particular reference to seasonality.

Physicians in the State of Wisconsin were contacted by mail and asked to report all cases of diabetes in patients under 20 yr diagnosed between 1 July 1982 and 30 June 1984 in order to study factors associated with seasonality in insulin-dependent diabetes mellitus (IDDM). Wisconsin's population is fairly homogeneous and is primarily middle socioeconomic class, small-town or rural, and of northern European Caucasian descent. The incidence of IDDM in winter was higher than in summer during the first year of the study, similarly to results of other studies. However, there was no significant winter peak in diagnosis during the second year. When monthly incidence rates from both years were combined, the increased evidence of IDDM in winter vs. summer was evident in males, but not in females. There appeared to be a spike in the number of new cases of IDDM in the first year of the study which was more evident in males. Such a spike is consistent with spikes in the incidence of IDDM occurring about the same time in Europe and in North America. The percentage of patients with antibody titres to Coxsackie virus and mycoplasma pneumoniae diagnosed during the first winter's peak were equal to those in nondiabetic controls. The distributions of HLA DR types of patients diagnosed in winter were no different from diabetics diagnosed in other seasons. The distribution of HLA DR types (5% DR2, 55% DR3, 82% DR4 and 38% DR3DR4) were similar to those of other groups of Caucasian subjects with IDDM. Also similarly to other studies of IDDM, 14% of the patients had thyroid microsomal antibody titers. The results of this study support the previously-advanced idea that winter might precipitate overt carbohydrate intolerance in individuals in whom insulin cell destruction is already well established (Diabetes, 36, 265-268, 1987). If this is true, studies of seasonality in IDDM might not be informative about the causation of IDDM.

Screening programs for congenital hypothyroidism. How can they be improved?

High-sensitivity neonatal hypothyroid screening tests are used throughout the country. Because of low specificity, primary care physicians are faced with an abundance of false-positive results that challenge the interpreting physician with clinical, economic, and medicolegal considerations. We surveyed 154 physicians caring for Wisconsin-born infants with the highest newborn-screen thyrotropin values in a two-year period. Our results indicated that (1) confirmation of thyroid normalcy is often delayed beyond 6 weeks of age; (2) there is wide variation among physicians regarding therapeutic goals if hypothyroidism is confirmed; and (3) physicians prefer autonomy in the management of congenital hypothyroidism. Modifications in hypothyroid screening programs may include confirmatory tests by a central laboratory (that distributes filter paper with all abnormal results), provision of a management decision tree for primary care physicians, and a one-time subsidy for a visit to a pediatric endocrinologist. We suggest that these modifications may improve the long-term outcome of hypothyroid infants identified by the screening program.