Universal neonatal hearing screening in Flanders reveals socio-demographic risk factors for hearing impairment.

INTRODUCTION: Permanent congenital hearing impairment (CHI) occurs in approximately 1.4 per 1,000 newborns. Early treatment and rehabilitation is essential to prevent the delayed development of speech and language. This paper describes the special collaborative approach of the Flemish screening programme. It also discusses the results and the new insights into socio-demographic risk factors for CHI. METHODS: In the period 1999-2008, the entire population of 628,337 newborns in Flanders was tested using an AABR hearing screener. Positive results were referred for confirmation of the CHI diagnosis to specialised referral centres. Socio-demographic factors were investigated to study any relationship with CHI. RESULTS: The referral rate after two screenings was 2.7-7.2 per thousand of screened babies depending on the screener used. All children were referred to specialised centres and there was almost no loss to follow-up. The diagnosis of hearing loss was confirmed in 77-82% of the babies referred. The socio-demographic factors of gender, birth order and birth length, initial feeding type, level of education and origin of the mother were found to be independent predictors of CHI. Most of these risk factors can be linked to poverty. The observation that 50% of babies with CHI have no risk factors from the classic AAP list may be partly explained by the non-inclusion of socio-demographic risk factors. CONCLUSIONS: This integrated programme opens up new perspectives for hearing-impaired babies. The social impact of the screening programme is considerable. A cluster of socio-demographic risk factors for CHI can be added to the classic AAP list.

Fifteen years of early hearing screening in Flanders: impact on language and education.

OBJECTIVES: To assess the impact of fifteen years of universal neonatal hearing screening in Flanders on language development and the educational setting. METHODOLOGY: An analysis of the database of Kind en Gezin from 1997 to 2012 and a long-term evaluation of the children referred to our centre after failed neonatal hearing screening. The CELF and PPVT language tests were performed. RESULTS: Between 1997 and August 2012, bilateral hearing loss was confirmed in 2393 children in Flanders, of whom 11.4% were referred to our tertiary centre. The educational setting and language development of 84 children older than 5 years was evaluated and 54% of them had additional disabilities. Of the children without additional disabilities, 84% attended mainstream schools; 42% of children with additional disabilities entered mainstream education with additional support. There was a significant correlation between the number of additional disabilities and the education level (p < 0.001) and between the degree of hearing loss and educational placement (p < 0.001). Data on language development were available for 76% of the children and a significant correlation could be demonstrated only between the results of the PPVT language and the number of additional handicaps (p < 0.008). CONCLUSIONS: The majority of children receiving early treatment after neonatal hearing screening enter mainstream education. The number of additional disabilities has a significant effect on education level and language development.

The health and economic burden of chickenpox and herpes zoster in Belgium.

Varicella-zoster virus causes chickenpox (CP) and after reactivation herpes zoster (HZ). Vaccines are available against both diseases warranting an assessment of the pre-vaccination burden of disease. We collected data from relevant Belgian databases and performed five surveys of CP and HZ patients. The rates at which a general practitioner is visited at least once for CP and HZ are 346 and 378/100 000 person-years, respectively. The average CP and HZ hospitalization rates are 5·3 and 14·2/100 000 person-years respectively. The direct medical cost for HZ is about twice as large as the direct medical cost for CP. The quality-adjusted life years lost for ambulatory CP patients consulting a physician is more than double that of those not consulting a physician (0·010 vs. 0·004). In conclusion, both diseases cause a substantial burden in Belgium.

Literature review on preschool vision screening.

Amblyopia results from degradation of the retinal image during a sensitive period of visual development. Amblyopia is the most common cause of visual loss in children. Because of the failure in detection and in treatment, amblyopia is still an important cause of visual loss in adults. Results from recent randomised trials in amblyopia should change our approach to screening and treatment. Based on the current evidence, if a single screening session is used, screening at school entry could be the most efficient screening moment. Between researchers, however, there still exists a lot of controversy on the benefit of visual screening.

Impact of early hearing screening and treatment on language development and education level: evaluation of 6 years of universal newborn hearing screening (ALGO) in Flanders, Belgium.

OBJECTIVES: Early intervention in hearing-impaired children may improve language outcomes and subsequent school and occupational performance. The objective of this study was to retrospectively analyze over 6 years the educational outcome and language development of a first cohort of children, detected by the Flemish universal newborn hearing screening (UNHS) program based on automated auditory brainstem response (AABR), with the oldest children being in primary school. METHODS: We studied 229 hearing-impaired children from 1998 till 2003. The following variables were considered: the age during the school year 2005-2006, the degree of hearing loss, additional impairments including presence of intellectual disability, school placement and early intervention. RESULTS: Analysis showed that 85.4% of the children with moderate, severe or profound hearing loss and no additional disability, older than 5.5 years, reach mainstream education. Further detailed description was provided for the outcomes of children with uni- and bilateral cochlear implants. Overall results stress that 46% of all children with a cochlear implant obtain mainstream education. Of all cochlear implant (CI) children above 5.5 years, without additional handicaps, 78.9% of children attend primary mainstream school. Data on language development show that up to 45% of the children with unilateral cochlear implant and no additional disabilities had normal to slight delay on language development. These data are fulfilling the goals stated by the JCIH and the American Academy of Pediatrics (AAP) in 2000. The role and impact of additional handicaps is discussed. The importance of early hearing loss identification and hearing therapy for appropriate language development is highlighted. Finally our preliminary results on children with bilateral cochlear implants without additional handicaps present an improved language development in comparison to unilateral CI-children. CONCLUSION: A vast majority of the children detected by the UNHS program, with moderate, severe or profound hearing loss and no additional disability, older than 5.5 years, reach mainstream education. Additional disabilities have a major influence.

Organisation of a universal newborn hearing screening programme in Flanders.

OBJECTIVE: Since 1998 an integrated universal newborn hearing screening programme (UNHSP) based on automated auditory brainstem response (AABR) has been implemented in Flanders. The protocol of the UNHSP is based on guidelines defined by the American Academy of Paediatrics (AAP). The aim of this paper is to report on the screening protocol and to assess its feasibility. METHODOLOGY: Descriptive study based upon an analysis of the screening results in the neonatal non-NICU population of Flanders between 1999 and 2004. The UNHSP, organized by Kind en Gezin (K&G), uses a 2-stage protocol: children with a refer at the first screening test are retested, and those with a refer at the retest are referred to a certified centre. Screening and referral centres communicate their data to a central database at K&G. RESULTS: From the beginning of 1999 until the end of 2004 a screening was offered to 97.91% of all eligible babies in Flanders; 91.5% of these babies were screened by K&G using the Algo Portable Newborn Screener. Three-quarters of the referred babies had a confirmed hearing loss. In 57.6% of these babies, hearing loss was bilateral. Some babies had a temporary hearing problem. The false positive rate after two tests was 0.53 per thousand. All ascertained babies started early intervention, most of them before the age of 4 months. CONCLUSIONS: K&G has succeeded in organizing a new, well-structured community-based UNHSP according to the guidelines of the AAP on Neonatal Hearing Screening.

A cross-sectional survey of the prevalence of Streptococcus pneumoniae nasopharyngeal carriage in Belgian infants attending day care centres.

Nasopharyngeal carriage is a major factor in the transmission of pneumococcal disease. The aim of this study was to determine the prevalence of asymptomatic nasopharyngeal carriage of Streptococcus pneumoniae and the distribution of serogroups and serotypes in children aged 3-36 months attending day care centres in Belgium. A single nasopharyngeal swab was cultured from 467 children attending 30 different day care centres between December 2000 and March 2001. S. pneumoniae isolates were serotyped and their antibiotic susceptibilities assessed by disk diffusion. The overall nasopharyngeal carriage rate for S. pneumoniae was 21% in the 467 children. None of the commonly accepted risk factors studied was associated significantly with carriage. Capsular serotypes isolated were 19F (27.3%), 6B (20.2%), 23F (19.2%), 19A (10.1%), 6A (7.1%), 14 (5.1%) and others (11.0%). Theoretical coverage by the seven-valent (serotypes 4, 6B, 9V, 14, 18C, 19F and 23F) pneumococcal conjugate vaccine was 73.7%. Fourteen (14.1%) of 99 strains were non-susceptible to penicillin, 48 (48.5%) to tetracycline and 61 (61.6%) to erythromycin. Theoretical coverage by the seven-valent pneumococcal conjugate vaccine was 93% for the penicillin-resistant serotypes, 69% for the tetracycline-resistant serotypes and 75% for the erythromycin-resistant serotypes. Use of the seven-valent pneumococcal conjugate vaccine could potentially reduce nasopharyngeal carriage of the antibiotic-resistant strains.

Standardization of measurement of beta-amyloid(1-42) in cerebrospinal fluid and plasma.

The standardization and clinical validation of the measurement of beta-amyloid(1-42) (Abeta42) in cerebrospinal fluid (CSF), plasma and urine is described using a commercially available sandwich-type ELISA with 21F12 and 3D6 as monoclonal antibodies. The INNOTEST beta-amyloid(1-42) allows the specific and reliable measurement of(1-42) amyloid peptides in CSF and plasma. The Abeta42 concentrations in serum and urine were below the detection limit. In plasma, no differences were found in Abeta42 levels between controls and patients with different neurodegenerative disorders (Alzheimer's disease (AD), Lewy body disease (LBD), others). In contrast, CSF-Abeta42 concentrations were lower in AD and LBD patients as compared to controls. No correlation was found in AD patients between CSF and plasma concentrations of Abeta42 or between CSF Abeta42 levels and blood-brain-barrier function. The quantitative outcome of the test is in part dependent on confounding factors such as tube type, freeze/thaw cycles, temperature of incubation, standard preparation protocol, and antibody selection. Notwithstanding these aspects, it emerged that Abeta42 is a useful biochemical marker for the diagnosis of AD patients, but there is a need for an international Abeta standard, a universally accepted protocol for CSF preparation, and a thorough evaluation of assay performance in function of the boundary conditions.

Quantification of tau phosphorylated at threonine 181 in human cerebrospinal fluid: a sandwich ELISA with a synthetic phosphopeptide for standardization.

Hyperphosphorylation of the microtubule-associated protein tau is specifically found in those brain cells affected in several tauopathies. Tau has also been consistently found to be present in the cerebrospinal fluid (CSF). Here we report the quantification in CSF of tau phosphorylated at Thr 181 using an immunoassay with a synthetic peptide for standardization. The choice of the peptide was based on fine mapping of a phospho-dependent antibody, AT270 (P(176)PAPKT(p)P(132))and a human specific tau antibody, HT7 (P(159)PGQK(163)). CSF-phospho-tau levels were increased in Alzheimer patients (23.5+/-10.1 pM, P<0.01) compared with age-matched controls (15.9+/-5.7 pM), while decreased in patients with frontotemporal dementia (8.6+/-3.9 pM; P<0.01). In every diagnostic group, a highly significant correlation was found between total tau and phospho-tau (Alzheimer's disease, r(2)=0.73; frontotemporal dementia, r(2)=0.43; Control, r(2)=0.42), suggesting that the degree of phosphorylation of CSF-tau changes in different clinical conditions.

Disease- and treatment-related elevation of the neurodegenerative marker tau in children with hematological malignancies.

Children acquire neuropsychologic dysfunctions after chemotherapy for hematologic malignancy. In this study, putative changes in levels of CSF-tau (a marker of neural dysintegrity) in leukemic children prior to and during chemotherapy were studied. Cerebrospinal fluid (CSF) samples were obtained before and during treatment from patients with B cell non-Hodgkin's lymphoma (NHL, n = 10), non-B cell acute lymphoblastic leukemia/NHL (non-B-ALL, n = 48), acute myeloid leukemia (AML, n = 9), other malignant diseases (n = 9), and six control children. A sandwich-type ELISA (INNOTEST hTAU-Ag) was used for measuring CSF-tau. Sixteen out of 50 patients with hematological malignancies, including the patients with proven leukemic CNS invasion, already showed high CSF-tau levels at baseline (>300 pg/ml). The pre-induction treatment for non-B-ALL, consisting of only corticosteroids and methotrexate (MTX), resulted in a significant increase of tau at day 8 (on average to 535 pg/ml). Larger increases as compared to baseline levels of CSF-tau were observed in patients treated for B-NHL with systemic vincristine, corticosteroids and cyclophosphamide, and intrathecal MTX (mean 776 pg/ml at day 8). In two AML patients with CNS invasion, CSF-tau increased during chemotherapy up to 1,500 and 948 pg/ml, respectively. In one non-B-ALL patient with MTX-induced clinical neurotoxicity, CSF-tau was above the detection limit of 2,000 pg/ml. Almost one-third of the patients with hematological malignancies had elevated CSF-tau levels at diagnosis. Transient high levels of CSF-tau, reaching levels observed in other neurodegenerative disorders, were observed during induction chemotherapy for non-B-ALL, B-NHL and CNS+ AML. The clinical implications of both observations will be the subject of further study.

The effectiveness of repeated cardiopulmonary resuscitation training in a school population.

At the end of a study program, evaluating the feasibility and the effectiveness of a unique training session on a school population, the majority of the students were asking for additional training opportunities. We therefore set up the present study with the purpose of evaluating skills, knowledge and attitude concerning CPR, after respectively one and two training sessions. 265 students from 4 different school levels were trained. 6 months later 134 answered a questionnaire and were again trained in CPR, 129 students answered the same questionnaire and were tested for their skills in CPR. Ten months later 75 students who had two training sessions answered again the questionnaire and 65 among them were tested for their skills. The two training sessions were identical, given by lay teachers priorly instructed in CPR, and consisted of a video-program and practical demonstration, followed by individual practice on training manikins. Both training sessions lasted 100 min. Evaluation of skills was performed by emergency physicians not involved in the training. Seventeen different items, representing each step in CPR were scored. Repeated training induces significant improvement of total skill scoring, without significant difference between boys and girls, but with improvement of scoring with class level. When looking at the different steps, the improvement in scoring is most impressive in certain steps which scored poorly after one training session, such as backward tilt of the head, a keystone in CPR. The steps concerning mouth-to-mouth breathing and external thoracic compressions reach, 10 months after the second training, an average of 1.6 out of 2 (80% correct) as compared to 1.44 out of 2 (71.9% correct) after one training. Knowledge concerning CPR does not increase significantly after the second training session. The time lapse of 10 months since the second training session may have played a role, although the methodology excluding interactive instruction may also explain this discrepancy. The influence on attitude shows that fear to apply CPR increased significantly after one training session and does not significantly lower after the second training. This attitude seems to be rather person-linked, for no correlation was found with age, theoretical knowledge or practical skill scoring. We have no way of knowing whether the statement concerning fear to apply CPR will correspond with such an attitude when confronted with a concrete emergency situation.