# ENDO 2019 debate — complete slide transcript Every distinct screen state detected in the recording (95 states, 65 distinct slides). Times are video timestamps; the session started at 11:45 AM CT on 26 March 2019. --- ## S01 — Endocrine Debate: Thyroid Disease in Pregnancy: To Screen, or Not to Screen? **Shown:** 00:00–00:38 **Detected states:** 00:19 **Keyframe:** `keyframes/kf_0001_000019.png` ### State 01 @ 00:19 - For - Alex Stagnaro-Green, MD, MHPE, MHA - Against - Kristien Boelaert, MD, PhD - Moderator - David S. Cooper, MD *Visual: Plain royal-blue title slide with a small green arrow pointer (presenter cursor); no charts.* --- ## S02 — (slide) **Shown:** 00:38–01:02 **Detected states:** 00:50, 01:10 **Keyframe:** `keyframes/kf_0002_000050.png` ### State 02 @ 00:50 - Screening refers to the use of simple tests across a healthy population in order to identify individuals who have disease, but do not yet have symptoms. - Example: breast cancer screening using mammography. *Visual: World Health Organization logo (top left); clip-art of a crowd under a magnifying glass with one figure highlighted in red (top right).* ### State 03 @ 01:10 - Screening refers to the use of simple tests across a healthy population in order to identify individuals who have disease, but do not yet have symptoms. - Example: breast cancer screening using mammography. - For this morning: will screening (and treating) pregnant women for thyroid disease improve obstetrical and neurodevelopmental outcomes? *Visual: World Health Organization logo (top left); clip-art of a crowd under a magnifying glass with one figure highlighted in red (top right).* *Note: incremental build: second bullet added* --- ## S03 — Screening Criteria **Shown:** 01:18–01:57 **Detected states:** 01:37, 02:10 **Keyframe:** `keyframes/kf_0004_000137.png` ### State 04 @ 01:37 - * Thyroid disease in pregnancy - ** Serum TSH; Serum TPO Ab - Adapted from: - Wilson JMG, Jungner G. Principles and Practice of Screening for Disease, World Health Organization, 1968 *Visual: Same slide with only the title visible (the 5 criteria have not yet appeared); WHO logo and crowd/magnifying-glass clip-art present.* *Note: incremental build: title-only state* ### State 05 @ 02:10 - (1) The condition* is common - (2) A screening tool** for the condition is readily available, reliable, inexpensive, and acceptable to the patient - (3) A intervention is available that favorably influences the disease and has limited adverse effects - (4) The costs of screening and intervention are cost-effective - (5) There is an agreed-upon policy on whom to treat. - * Thyroid disease in pregnancy - ** Serum TSH; Serum TPO Ab - Adapted from: - Wilson JMG, Jungner G. Principles and Practice of Screening for Disease, World Health Organization, 1968 *Visual: WHO logo top-left; same crowd/magnifying-glass clip-art top-right; numbered screening criteria with asterisked footnotes.* *Note: incremental build: 5 criteria revealed* --- ## S04 — The Debaters **Shown:** 02:22–02:48 **Detected states:** 02:35 **Keyframe:** `keyframes/kf_0006_000235.png` ### State 06 @ 02:35 - For screening - Dr.. Alex Stagnaro-Green is the Regional Dean of the University of Illinois College of Medicine Rockford and is Professor of Medicine, Obstetrics and Gynecology, and Medical Education. - Against screening - Dr.. Kristien Boelaert is a Reader in Endocrinology at the University of Birmingham and a Consultant Endocrinologist at University Hospitals Birmingham, UK. *Visual: Two small portrait photos at left: Dr. Alex Stagnaro-Green (above 'For screening') and Dr. Kristien Boelaert (above 'Against screening'); green arrow pointer.* --- ## S05 — Endocrine Debate: Thyroid Disease in Pregnancy: To Screen, or Not to Screen? **Shown:** 02:48–03:38 **Detected states:** 03:13 **Keyframe:** `keyframes/kf_0007_000313.png` ### State 07 @ 03:13 - Audience Poll - Frame the Position/Share Evidence - Advocate For the Motion (Dr. Stagnaro-Green) - Advocate Against the Motion (Dr. Boeleart) - Rebuttals - Advocate For the Motion - Advocate Against the Motion - Questions from Audience *Visual: Agenda bullet list on solid blue background; green arrow pointer.* *Note: keyframe is before the 'Final Statements' sub-bullets were added (~t=200s, not captured in the 95-state list - see report)* --- ## S06 — SESSION PARTICIPATION AND EVALUATIONS USING THE ENDO 2019 APP **Shown:** 03:38–03:52 **Detected states:** 03:45, 58:09 **Keyframe:** `keyframes/kf_0008_000345.png` ### State 08 @ 03:45 - STEP 1 Find the session - STEP 2 Tap the Participate Evaluate button - Complete session evaluations by clicking Evaluate This Session - Poll questions will appear once the speaker arrives to a question slide - Click on the question to respond - Click Ask to submit a question - END 2019 *Visual: Two smartphone screenshots of the ENDO 2019 app (session OR07 Growth, Puberty, and Insulin Action and Resistance; Room 356; Saturday, March 23 11:30 AM - 1:00 PM; CME/MOC 1.50), blue arrows with STEP 1 'Find the session' / STEP 2 'Tap the Participate Evaluate button'; app tags: Evaluate This Session, Polls, Question 1, Social Q&A, Ask, ADD TO MY SCHEDULE; ENDO 2019 logo.* --- ## S07 — Question **Shown:** 03:52–04:02 **Detected states:** 03:57, 04:25, 58:20, 59:08 **Keyframe:** `keyframes/kf_0009_000357.png` ### State 09 @ 03:57 - 1. Are you in favor of screening all pregnant women for thyroid dysfunction? - – Yes - – No *Visual: Plain purple question slide; red banner at the bottom reads 'LIVE POLLING IS THE NEXT SLIDE'; green arrow pointer.* --- ## S08 — 1. Are you in favor of screening all pregnant women for thyroid dysfunction? **Shown:** 04:03–04:14 **Detected states:** 04:09, 04:37, 58:34, 59:19 **Keyframe:** `keyframes/kf_0010_000409.png` ### State 10 @ 04:09 - Yes - No - 6 (yellow countdown box, bottom-right) *Visual: White live-poll screen of the ENDO 2019 app: question at top, 'Yes'/'No' options, large yellow countdown box bottom-right showing '6'.* --- ## S09 — 1. Are you in favor of screening all pregnant women for thyroid dysfunction? **Shown:** 04:15–04:20 **Detected states:** 04:18, 04:44, 58:42, 59:28 **Keyframe:** `keyframes/kf_0011_000418.png` ### State 11 @ 04:18 - Yes 71% - No 29% - Poll is Locked *Visual: White live-poll results screen of the ENDO 2019 app: question at top, Yes/No rows with percentages and horizontal bars (yellow for Yes, green for No), grey label 'Poll is Locked' bottom-right.* --- ## S07 — Question **Shown:** 04:20–04:30 **Detected states:** 03:57, 04:25, 58:20, 59:08 **Keyframe:** `keyframes/kf_0012_000425.png` ### State 12 @ 04:25 - 2. Are you in favor of screening all pregnant women for thyroid autoimmunity? - – Yes - – No *Visual: Plain purple question slide; red banner at the bottom reads 'LIVE POLLING IS THE NEXT SLIDE'; green arrow pointer.* --- ## S08 — 2. Are you in favor of screening all pregnant women for thyroid autoimmunity? **Shown:** 04:32–04:42 **Detected states:** 04:09, 04:37, 58:34, 59:19 **Keyframe:** `keyframes/kf_0013_000437.png` ### State 13 @ 04:37 - Yes - No - 6 (yellow countdown box, bottom-right) *Visual: White live-poll screen of the ENDO 2019 app: question at top, 'Yes'/'No' options, large yellow countdown box bottom-right showing '6'.* --- ## S09 — 2. Are you in favor of screening all pregnant women for thyroid autoimmunity? **Shown:** 04:42–04:47 **Detected states:** 04:18, 04:44, 58:42, 59:28 **Keyframe:** `keyframes/kf_0014_000444.png` ### State 14 @ 04:44 - Yes 35% - No 65% - Poll is Locked *Visual: White live-poll results screen of the ENDO 2019 app: question at top, Yes/No rows with percentages and horizontal bars (yellow for Yes, green for No), grey label 'Poll is Locked' bottom-right.* --- ## S11 — Select your presentation **Shown:** 04:50–05:01 **Detected states:** 04:55, 22:10, 35:52, 40:51, 55:33, 57:58 **Keyframe:** `keyframes/kf_0015_000455.png` ### State 15 @ 04:55 - Select your presentation - My Files - Change Session - La Nouvelle B - Endocrine Debate Thyroid Dis... *Visual: Menu screen; the 'David Cooper 11:45 AM - 12:45 PM' card is highlighted/selected with 'Start' and 'My Files' buttons; cards also list Kristien Boelaert and Alex Stagnaro-Green sessions.* --- ## S12 — UNIVERSAL SCREENING FOR THYROID DISEASE IN PREGNANCY SHOULD BE PERFORMED **Shown:** 05:06–05:33 **Detected states:** 05:19 **Keyframe:** `keyframes/kf_0016_000519.png` ### State 16 @ 05:19 - Alex Stagnaro-Green, MD, MHPE, MHA - University of Illinois College of Medicine Rockford *Visual: Red title slide with a cropped Renaissance-style painting of a mother and child with an older woman (Madonna and Child); green arrow pointer.* --- ## S13 — To Screen or Not to Screen: That is the Question **Shown:** 05:40–06:12 **Detected states:** 05:56 **Keyframe:** `keyframes/kf_0017_000556.png` ### State 17 @ 05:56 - *(no text on screen)* *Visual: Collage of 7-8 full-page journal-article screenshots (Clinical Thyroidology 'Comparison of universal...', Eur J Endocrinol 'Universal screening detects two times more thyroid disorders in early pregnancy...', BMJ 'Universal screening...', Lancet 'Universal screening in early pregnancy and treatment of overt and subclinical thyroid dysfunction...', NEJM 'Universal screening...', a Perspectives/Editorial, Frontiers in Endocrinology 'Thyroid Screening in Early Pregnancy: Pros and Cons'); green boxes/arrows and 'Free' tags highlight supportive sentences.* --- ## S14 — (slide) **Shown:** 06:12–06:39 **Detected states:** 06:26 **Keyframe:** `keyframes/kf_0018_000626.png` ### State 18 @ 06:26 - "You can't sit on the fence forever. It is very uncomfortable for the backside." - -Terry Davies - 2007 *Visual: Red quote slide over a photo of a wrought-iron fence in front of a building, decorated with red ribbon graphics and three logos (stylised 'M', a blue square emblem, and the AACE seal).* --- ## S15 — Criteria for Screening **Shown:** 06:39–06:56 **Detected states:** 06:48, 11:08, 12:08, 15:00 **Keyframe:** `keyframes/kf_0019_000648.png` ### State 19 @ 06:48 - 1. The condition is common. - 2. Screening tool is readily available, reliable, inexpensive and acceptable. - 3. Intervention favorably influences the disease with limited adverse effects. - 4. Screening and intervention are cost-effective. - 5. Agreed-upon policy on whom to treat. - Wilson and Junger (1968) *Visual: Red slide: white box listing the 5 Wilson-Junger screening criteria at left; large blue UN/World Health Organization emblem at right.* --- ## S16 — Prevalence in the Published Literature **Shown:** 06:56–07:28 **Detected states:** 07:12 **Keyframe:** `keyframes/kf_0020_000712.png` ### State 20 @ 07:12 - Condition | Reported Prevalence Range - Overt Hypothyroidism - 0 - 13.1% - Subclinical Hypothyroidism - 1.5 - 42.9% - Isolated Hypothyroxinemia - 0.18 - 31% - Overt Hyperthyroidism - 0 - 2.5% - Subclinical Hyperthyroidism - 0.3 - 13% *Visual: Two-column table with dark-blue header (Condition | Reported Prevalence Range), 5 rows alternating white/light-blue.* --- ## S17 — Differences in Diagnostic Criteria Mask the True Prevalence of Thyroid Disease in Pregnancy **Shown:** 07:28–08:08 **Detected states:** 07:48 **Keyframe:** `keyframes/kf_0021_000748.png` ### State 21 @ 07:48 - Need consistent criteria to determine true prevalence - Meta analysis of all previously available data - Studies grouped based on criteria for diagnosis - For Hypothyroidism: - Gold-standard 97.5th percentile TSH cutoff is most accurate - For Hyperthyroidism: - Thyroid function testing done in 2nd trimester is most accurate - Dong & Stagnaro-Green, Thyroid 2019 *Visual: Text slide, no chart: 5 bullets (two with sub-bullets for Hypo- and Hyperthyroidism) and citation line.* --- ## S18 — Prevalence of Overt Hypothyroidism Based on TSH Cutoff Values **Shown:** 08:08–08:45 **Detected states:** 08:27 **Keyframe:** `keyframes/kf_0022_000827.png` ### State 22 @ 08:27 - % Prevalence (y-axis 0.00% - 3.00%) - All N = 43 - 0.61% - 97.5th Percentile N = 19 - 0.50% - 95th Percentile N = 4 - 1.50% - ATA 2011^ N = 12 - 1.33% - TSH > 4* N = 9 - 0.80% - TSH Cutoff Criteria - Dong and Stagnaro-Green, Thyroid 2019 *Visual: Vertical bar chart, % prevalence y-axis 0-3%, red '% Prevalence' label; bars: All 0.61% (N=43), 97.5th Percentile 0.50% (N=19; highlighted with red border), 95th Percentile 1.50% (N=4), ATA 2011^ 1.33% (N=12), TSH >4* 0.80% (N=9); red banner 'TSH Cutoff Criteria'.* --- ## S19 — Prevalence of Subclinical Hypothyroidism Based on TSH Cutoff Values **Shown:** 08:45–09:18 **Detected states:** 09:02 **Keyframe:** `keyframes/kf_0023_000902.png` ### State 23 @ 09:02 - % Prevalence (y-axis 0.00% - 25.00%) - All N = 56 - 5.10% - 97.5th Percentile N = 24 - 3.47% - 95th Percentile N = 4 - 3.89% - ATA 2011^ N = 25 - 14.39%* - TSH > 4^ N = 8 - 4.05% - TSH Cutoff Criteria - Dong and Stagnaro-Green, Thyroid 2019 *Visual: Vertical bar chart, % prevalence y-axis 0-25%; bars: All 5.10% (N=56), 97.5th Percentile 3.47% (N=24; highlighted with red border), 95th Percentile 3.89% (N=4), ATA 2011^ 14.39%* (N=25), TSH >4^ 4.05% (N=8); red banner 'TSH Cutoff Criteria'.* --- ## S20 — Prevalence of Overt Hyperthyroidism Based on Timing of Screening **Shown:** 09:18–09:38 **Detected states:** 09:28 **Keyframe:** `keyframes/kf_0024_000928.png` ### State 24 @ 09:28 - % Prevalence (y-axis 0.00% - 1.60%) - All* N = 21 - 0.64% - 1st Trimester^ N = 14 - 0.91% - 2nd Trimester^ N = 6 - 0.65% - TSH Cutoff Criteria - Dong and Stagnaro-Green, Thyroid 2019 *Visual: Vertical bar chart, % prevalence y-axis 0-1.6%; bars: All* 0.64% (N=21), 1st Trimester^ 0.91% (N=14), 2nd Trimester^ 0.65% (N=6; highlighted with red border); red banner 'TSH Cutoff Criteria'.* --- ## S21 — Thyroid Disease Prevalence in Pregnancy **Shown:** 09:38–10:30 **Detected states:** 10:04 **Keyframe:** `keyframes/kf_0025_001004.png` ### State 25 @ 10:04 - Prevalence Rates: - Overt Hypothyroidism 0.50% - Subclinical Hypothyroidism 3.47% - Isolated Hypothyroxinemia 2.05% - Overt Hyperthyroidism T1 0.91% - Overt Hyperthyroidism T2 0.65% - Subclinical Hyperthyroidism T1 2.18% - Subclinical Hyperthyroidism T2 0.98% - Thyroid Autoimmunity: TPOAb 5-14%; TgAb 3-18% (De Leo & Pearce, 2018) - Dong & Stagnaro-Green, Thyroid 2019 *Visual: Two boxes: left table 'Prevalence Rates:' (rows Overt Hypothyroidism 0.50%, Subclinical Hypothyroidism 3.47%, Isolated Hypothyroxinemia 2.05%, Overt Hyperthyroidism T1 0.91%, Overt Hyperthyroidism T2 0.65%, Subclinical Hyperthyroidism T1 2.18%, Subclinical Hyperthyroidism T2 0.98%; first row outlined red); right box 'Thyroid Autoimmunity' (TPOAb 5-14%, TgAb 3-18%, De Leo & Pearce, 2018).* --- ## S22 — BUILD slide: 6-column checklist of screening criteria vs thyroid conditions **Shown:** 10:30–11:02 **Detected states:** 10:46, 11:52, 14:44, 19:12, 20:10 **Keyframe:** `keyframes/kf_0026_001046.png` ### State 26 @ 10:46 - (table) rows = screening criteria; columns = Overt Hypo, Subclinical Hypo, Isolated Hypothyroxinemia, Overt Hyper, Subclinical Hyper, Thyroid Auto-immunity - Row 1 'The condition is common.': + for all six columns (only row filled so far) *Visual: Checklist table build state: only criterion 1 row has green '+' cells across all six condition columns; rows 2-5 still empty.* *Note: build state 1 of 5* --- ## S15 — Criteria for Screening **Shown:** 11:02–11:13 **Detected states:** 06:48, 11:08, 12:08, 15:00 **Keyframe:** `keyframes/kf_0027_001108.png` ### State 27 @ 11:08 - 1. The condition is common. - 2. Screening tool is readily available, reliable, inexpensive and acceptable. - 3. Intervention favorably influences the disease with limited adverse effects. - 4. Screening and intervention are cost-effective. - 5. Agreed-upon policy on whom to treat. - Wilson and Junger (1968) *Visual: Red slide: white box listing the 5 Wilson-Junger screening criteria at left; large blue UN/World Health Organization emblem at right.* *Note: near-duplicate of state 19 (same slide re-shown; only cursor position differs)* --- ## S23 — Test Acceptable to Population **Shown:** 11:13–11:42 **Detected states:** 11:27 **Keyframe:** `keyframes/kf_0028_001127.png` ### State 28 @ 11:27 - Blood Draw at 1st Prenatal/Preconception Visit - Type and Screen - CBC - Rubella & Varicella IgG, RPR, HBsAg, HIV - Thyroid Screening - TSH *Visual: Red slide with photos of blood-collection tubes: 'Blood Draw at 1st Prenatal/Preconception Visit' showing Type and Screen (pink/red tube), CBC (lavender tube), and bottom row of yellow tubes for Rubella & Varicella IgG, RPR, HBsAg, HIV; 'Thyroid Screening' column shows a single TSH (yellow) tube.* --- ## S22 — BUILD slide: 6-column checklist of screening criteria vs thyroid conditions **Shown:** 11:42–12:04 **Detected states:** 10:46, 11:52, 14:44, 19:12, 20:10 **Keyframe:** `keyframes/kf_0029_001152.png` ### State 29 @ 11:52 - Row 1 'The condition is common.': + all columns - Row 2 'Screening tool-readily available, reliable, cheap and acceptable.': + all columns *Visual: Checklist table build state: rows 1 and 2 filled with green '+' across all six columns; rows 3-5 empty.* *Note: build state 2 of 5* --- ## S15 — Criteria for Screening **Shown:** 12:04–12:13 **Detected states:** 06:48, 11:08, 12:08, 15:00 **Keyframe:** `keyframes/kf_0030_001208.png` ### State 30 @ 12:08 - 1. The condition is common. - 2. Screening tool is readily available, reliable, inexpensive and acceptable. - 3. Intervention favorably influences the disease with limited adverse effects. - 4. Screening and intervention are cost-effective. - 5. Agreed-upon policy on whom to treat. - Wilson and Junger (1968) *Visual: Red slide: white box listing the 5 Wilson-Junger screening criteria at left; large blue UN/World Health Organization emblem at right.* *Note: near-duplicate of state 19 (same slide re-shown)* --- ## S24 — Overt Hypothyroidism Correlation Studies **Shown:** 12:15–12:52 **Detected states:** 12:34 **Keyframe:** `keyframes/kf_0031_001234.png` ### State 31 @ 12:34 - GH/Preeclampsia: Correlation found - Davis et al. 1988, Leung et al. 1993, Buckshee et al. 1997, Sahu et al. 2010, Sharmeen et al. 2014 - Placental Abruption: Davis et al. 1988 - Low Birth Weight: Leung et al. 1993, Su et al. 2011 - Premature Birth: Buckshee et al. 1997, Yang et al. 2018 | No correlation: Abalovich et al. 2002, Nambiar et al. 2011 - Offspring Cognitive Delay/Deficits: Haddow et al. 1999, Klein et al. 2001 - Miscarriage: Abalovich et al. 2002, Hallengren et al. 2009, Nambiar et al. 2011, Aguayo et al. 2013, Taylor et al. 2014 - GDM: Sahu et al. 2010, Sharmeen et al. 2014 *Visual: Table: Outcome Studied | Correlation Found | No Correlation Found. Rows GH/Preeclampsia (Davis 1988, Leung 1993, Buckshee 1997, Sahu 2010, Sharmeen 2014), Placental Abruption (Davis 1988), Low Birth Weight (Leung 1993, Su 2011), Premature Birth (Buckshee 1997, Yang 2018 | Abalovich 2002, Nambiar 2011), Offspring Cognitive Delay/Deficits (Haddow 1999, Klein 2001), Miscarriage (Abalovich 2002, Hallengren 2009, Nambiar 2011, Aguayo 2013, Taylor 2014), GDM (Sahu 2010, Sharmeen 2014).* --- ## S25 — Overt Hypothyroidism Treatment Studies **Shown:** 12:52–13:06 **Detected states:** 12:59 **Keyframe:** `keyframes/kf_0032_001259.png` ### State 32 @ 12:59 - GH/Preeclampsia: Treatment benefit - Tan et al. 2006 | No benefit - Wolfberg et al. 2005 - Offspring Cognitive Delay/Deficits: Treatment benefit - Haddow et al. 1995, Downing et al. 2012 | No benefit - Liu et al. 1994, Lazarus et al. 2012, Hales et al. 2018 - Miscarriage: Treatment benefit - Abalovich et al. 2002, Hallengren et al. 2009, Hirsch et al. 2013, Taylor et al. 2014 *Visual: Table: Outcome Studied | Treatment Benefit | Treatment No Benefit. Rows GH/Preeclampsia (Tan 2006 | Wolfberg 2005); Offspring Cognitive Delay/Deficits (Haddow 1995, Downing 2012 | Liu 1994, Lazarus 2012, Hales 2018); Miscarriage (Abalovich 2002, Hallengren 2009, Hirsch 2013, Taylor 2014).* --- ## S26 — Overt Hyperthyroidism Correlation Studies **Shown:** 13:06–13:28 **Detected states:** 13:17 **Keyframe:** `keyframes/kf_0033_001317.png` ### State 33 @ 13:17 - Low Birth Weight: Correlation found - Davis et al. 1989, Momotami et al. 1991, Millar et al. 1994, Phoojaroenchanachai et al. 2001, Luewan et al. 2011, Andersen et al. 2013 - Miscarriage: Davis et al. 1989, Momotami et al. 1991, Andersen et al. 2014, Yang et al. 2018 - Congenital Abnormalities: Davis et al. 1989, Momotami et al. 1991 - Preterm Delivery: Davis et al. 1989, Luewan et al. 2011 - Preeclampsia: Millar et al. 1994 | No correlation: Luewan et al. 2011 - Heart Failure: Davis et al. 1989 *Visual: Table: Outcome Studied | Correlation Found | No Correlation Found. Rows Low Birth Weight (Davis 1989, Momotami 1991, Millar 1994, Phoojaroenchanachai 2001, Luewan 2011, Andersen 2013); Miscarriage (Davis 1989, Momotami 1991, Andersen 2014, Yang 2018); Congenital Abnormalities (Davis 1989, Momotami 1991); Preterm Delivery (Davis 1989, Luewan 2011); Preeclampsia (Millar 1994 | Luewan 2011); Heart Failure (Davis 1989).* --- ## S27 — Overt Hyperthyroidism Treatment Studies **Shown:** 13:28–13:48 **Detected states:** 13:38 **Keyframe:** `keyframes/kf_0034_001338.png` ### State 34 @ 13:38 - Low Birth Weight: Treatment benefit - Davis et al. 1989, Millar et al. 1994, Phoojaroenchanachai 2001, Aggarawal et al. 2014 - Miscarriage: Momotami et al. 1991 - Preterm Delivery: Davis et al. 1989, Momotami et al. 1991 *Visual: Table: Outcome Studied | Treatment Benefit | Treatment No Benefit. Rows Low Birth Weight (Davis 1989, Millar 1994, Phoojaroenchanachai 2001, Aggarawal 2014); Miscarriage (Momotami 1991); Preterm Delivery (Davis 1989, Momotami 1991).* --- ## S28 — Thyroid Autoimmunity Correlation Studies **Shown:** 13:48–14:15 **Detected states:** 14:02 **Keyframe:** `keyframes/kf_0035_001402.png` ### State 35 @ 14:02 - Miscarriage: Correlation found - Stagnaro-Green et al. 1990, Glinoer et al. 1991, Lejeune et al. 1993, Netto et al. 2004, Negro et al. 2006, Ghafoor et al. 2006, Nambiar et al. 2011, Lepoutre et al. 2012, Liu et al. 2014, Iqbal et al. 2016 | No correlation: Iijima et al. 1996, Plowden et al. 2016 - Preterm Delivery: Correlation found - Stagnaro-Green et al. 2005, Negro et al. 2006, Ghafoor et al. 2006, Karakosta et al. 2012, Kumru et al. 2015, Saki et al. 2015, Iqbal et al. 2016, Meena et al. 2016, Han et al. 2018 | No correlation: Iijima et al. 1996, Haddow et al. 2010, Nambiar et al. 2011 - Offspring Cognitive Delay: Pop et al. 1995, Wasserman et al. 2012 *Visual: Table: Outcome Studied | Correlation Found | No Correlation Found. Rows Miscarriage (Stagnaro-Green 1990, Glinoer 1991, Lejeune 1993, Netto 2004, Negro 2006, Ghafoor 2006, Nambiar 2011, Lepoutre 2012, Liu 2014, Iqbal 2016 | Iijima 1996, Plowden 2016); Preterm Delivery (Stagnaro-Green 2005, Negro 2006, Ghafoor 2006, Karakosta 2012, Kumru 2015, Saki 2015, Iqbal 2016, Meena 2016, Han 2018 | Iijima 1996, Haddow 2010, Nambiar 2011); Offspring Cognitive Delay (Pop 1995, Wasserman 2012).* --- ## S29 — Thyroid Autoimmunity Treatment Studies **Shown:** 14:15–14:30 **Detected states:** 14:22 **Keyframe:** `keyframes/kf_0036_001422.png` ### State 36 @ 14:22 - Miscarriage: Treatment benefit - Negro et al. 2006, Negro et al. 2016, Lepoutre et al. 2012 | No benefit: Dhillin-Smith, March 23, 2019 - Preterm Delivery: Treatment benefit - Negro et al. 2006, Negro et al. 2016, Nazarpour et al. 2017 *Visual: Table: Outcome Studied | Treatment Benefit | Treatment No Benefit. Rows Miscarriage (Negro 2006, Negro 2016, Lepoutre 2012 | Dhillin-Smith, March 23, 2019); Preterm Delivery (Negro 2006, Negro 2016, Nazarpour 2017).* --- ## S22 — BUILD slide: 6-column checklist of screening criteria vs thyroid conditions **Shown:** 14:30–14:58 **Detected states:** 10:46, 11:52, 14:44, 19:12, 20:10 **Keyframe:** `keyframes/kf_0037_001444.png` ### State 37 @ 14:44 - Row 1: + all columns - Row 2: + all columns - Row 3 'Intervention favorably influences the disease': Overt Hypo +, Subclinical Hypo +/-, Isolated Hypothyroxinemia -, Overt Hyper +, Subclinical Hyper -, Thyroid Autoimmunity +/- *Visual: Checklist table build state: rows 1-3 filled; row 3 shows + for Overt Hypo and Overt Hyper, +/- for Subclinical Hypo and Thyroid Autoimmunity, - for Isolated Hypothyroxinemia and Subclinical Hyper; rows 4-5 empty.* *Note: build state 3 of 5* --- ## S15 — Criteria for Screening **Shown:** 14:58–15:02 **Detected states:** 06:48, 11:08, 12:08, 15:00 **Keyframe:** `keyframes/kf_0038_001500.png` ### State 38 @ 15:00 - 1. The condition is common. - 2. Screening tool is readily available, reliable, inexpensive and acceptable. - 3. Intervention favorably influences the disease with limited adverse effects. - 4. Screening and intervention are cost-effective. - 5. Agreed-upon policy on whom to treat. - Wilson and Junger (1968) *Visual: Red slide: white box listing the 5 Wilson-Junger screening criteria at left; large blue UN/World Health Organization emblem at right.* *Note: near-duplicate of state 19 (same slide re-shown)* --- ## S30 — Cost Effectiveness Analysis **Shown:** 15:02–16:04 **Detected states:** 15:33 **Keyframe:** `keyframes/kf_0039_001533.png` ### State 39 @ 15:33 - CEA-analytic tool comparing relative costs and benefits of at least two courses of action - COST (intervention A- B): Blood Test, Extra Visits, Treatment - BENEFIT (effectiveness A-B): Decrease miscarriage, Decrease preterm delivery, Improve IQ of child *Visual: Red slide: CEA definition; a balance-beam diagram: COST (intervention A- B) list = Blood Test, Extra Visits, Treatment; BENEFIT (effectiveness A-B) list = Decrease miscarriage, Decrease preterm delivery, Improve IQ of child; blue beam with white triangle fulcrum.* --- ## S31 — Incremental Cost Effectiveness Ratio **Shown:** 16:04–17:26 **Detected states:** 16:44 **Keyframe:** `keyframes/kf_0040_001644.png` ### State 40 @ 16:44 - (Cost of Intervention A-Cost of Intervention B) - / (Effectiveness of A-Effectiveness of B) - Effectiveness measured in Quality Adjusted Life Years (QALYs), - QALY calculated = (0 death, 1=optimal life) X (years) - ICER in US < $50,000/QALY deemed cost effective *Visual: Formula slide: ICER = (Cost of Intervention A - Cost of Intervention B) / (Effectiveness of A - Effectiveness of B); QALY definitions; bottom line 'ICER in US < $50,000/QALY deemed cost effective'.* --- ## S32 — Cost-Effectiveness of Universal Screening **Shown:** 17:26–18:28 **Detected states:** 17:56 **Keyframe:** `keyframes/kf_0041_001756.png` ### State 41 @ 17:56 - Dosiou et al. 2008 - USA - Universal TSH VS No Screening - Dominant - Thung et al. 2009 - USA - Universal TSH VS No Screening - Cost-Effective - Dosiou et al. 2012 - USA - Universal TSH and TPO VS Targeted - Cost-Effective - Donnay Candil et al. 2015 - Spain - Universal TSH and TPO VS Targeted - Dominant - Dosiou, 2012. Universal screening was cost-effective compared to both no screening and targeted screening even when eliminated any benefit of identifying and treating SCH *Visual: Table: Study | Location | Comparison | Universal Screening Was...; rows Dosiou et al. 2008 USA Universal TSH VS No Screening Dominant; Thung et al. 2009 USA Universal TSH VS No Screening Cost-Effective; Dosiou et al. 2012 USA Universal TSH and TPO VS Targeted Cost-Effective (highlighted row); Donnay Candil et al. 2015 Spain Universal TSH and TPO VS Targeted Dominant. Bottom red text: 'Dosiou, 2012. Universal screening was cost-effective compared to both no screening and targeted screening even when eliminated any benefit of identifying and treating SCH'.* --- ## S33 — Cost-Effectiveness - Overt Hyperthyroidism Logic Argument **Shown:** 18:28–18:58 **Detected states:** 18:43 **Keyframe:** `keyframes/kf_0042_001843.png` ### State 42 @ 18:43 - Treatment of Overt Hyperthyroidism is beneficial - Screening method for Overt Hyperthyroidism is the same as for hypothyroidism - Screening for and treatment of Overt Hypothyroidism - shown to be cost-effective - Therefore Screening for Overt Hyperthyroidism can be assumed to be even more cost-effective *Visual: Bulleted logic argument (4 bullets) on red background; no chart.* --- ## S22 — BUILD slide: 6-column checklist of screening criteria vs thyroid conditions **Shown:** 18:58–19:26 **Detected states:** 10:46, 11:52, 14:44, 19:12, 20:10 **Keyframe:** `keyframes/kf_0043_001912.png` ### State 43 @ 19:12 - Row 1: + all columns - Row 2: + all columns - Row 3: Overt Hypo +, Subclinical Hypo +/-, Isolated Hypothyroxinemia -, Overt Hyper +, Subclinical Hyper -, Thyroid Autoimmunity +/- - Row 4 'Screening and intervention are cost-effective': Overt Hypo +, Subclinical Hypo +/-, Isolated Hypothyroxinemia -, Overt Hyper +, Subclinical Hyper -, Thyroid Autoimmunity +/- *Visual: Checklist table build state: rows 1-4 filled; row 5 still empty.* *Note: build state 4 of 5* --- ## S34 — Agreement To Treat Meter **Shown:** 19:28–20:04 **Detected states:** 19:46 **Keyframe:** `keyframes/kf_0044_001946.png` ### State 44 @ 19:46 - Never Treat: Isolated Hypothyroxinemia, Subclinical Hyperthyroidism - Unclear if Should Treat: Subclinical Hypothyroidism, Thyroid Autoimmunity - Always Treat: Overt Hypo, Overt Hyper *Visual: Horizontal blue meter with a blue dot: left 'Never Treat', centre 'Unclear if Should Treat', right 'Always Treat'; below: Never Treat = Isolated Hypothyroxinemia, Subclinical Hyperthyroidism; Unclear = Subclinical Hypothyroidism, Thyroid Autoimmunity; Always Treat = Overt Hypo, Overt Hyper.* --- ## S22 — BUILD slide: 6-column checklist of screening criteria vs thyroid conditions **Shown:** 20:04–20:17 **Detected states:** 10:46, 11:52, 14:44, 19:12, 20:10 **Keyframe:** `keyframes/kf_0045_002010.png` ### State 45 @ 20:10 - Row 1: + all columns - Row 2: + all columns - Row 3: Overt Hypo +, Subclinical Hypo +/-, Isolated Hypothyroxinemia -, Overt Hyper +, Subclinical Hyper -, Thyroid Autoimmunity +/- - Row 4: Overt Hypo +, Subclinical Hypo +/-, Isolated Hypothyroxinemia -, Overt Hyper +, Subclinical Hyper -, Thyroid Autoimmunity +/- - Row 5 'Agreed-upon policy on whom to treat': Overt Hypo +, Subclinical Hypo -, Isolated Hypothyroxinemia -, Overt Hyper +, Subclinical Hyper -, Thyroid Autoimmunity +/- *Visual: Checklist table build state: all 5 rows filled (complete table).* *Note: build state 5 of 5 (final)* --- ## S35 — Recommended Universal Screening **Shown:** 20:17–20:46 **Detected states:** 20:32 **Keyframe:** `keyframes/kf_0046_002032.png` ### State 46 @ 20:32 - AACE (1999) - Pre-Pregnancy - TSH - AACE (2002) - Pre-Pregnancy or 1st Trimester - TSH - Endocrine Society (Minority) (2007) - 1st Visit - TSH - Italian Thyroid Association & Italian Association of Clinical Endocrinologists (2011) - 1st Visit - TSH, fT4 - Endocrine Society (Minority) (2012) - 1st Visit - TSH - Spanish Society of Endocrinology and Nutrition jointly with Spanish Society of Gynecology and Obstetrics (2012) - Pre-Pregnancy or 1st Trimester - TSH, fT4 Reflex - European Thyroid Association (Majority) (2014) - 1st Trimester - TSH, fT4 Reflex *Visual: Table: Professional Society | Timing | TSH | fT4 (check marks); rows AACE 1999 Pre-Pregnancy TSH ✓; AACE 2002 Pre-Pregnancy or 1st Trimester TSH ✓; Endocrine Society (Minority) 2007 1st Visit TSH ✓; Italian Thyroid Association & Italian Association of Clinical Endocrinologists 2011 1st Visit TSH ✓ fT4 ✓; Endocrine Society (Minority) 2012 1st Visit TSH ✓; Spanish Society of Endocrinology and Nutrition jointly with Spanish Society of Gynecology and Obstetrics 2012 Pre-Pregnancy or 1st Trimester TSH ✓ fT4 Reflex; European Thyroid Association (Majority) 2014 1st Trimester TSH ✓ fT4 Reflex.* --- ## S36 — ATA 2017 Recommendation - Targeted Screening **Shown:** 20:46–21:06 **Detected states:** 20:56 **Keyframe:** `keyframes/kf_0047_002056.png` ### State 47 @ 20:56 - History of or current signs of thyroid dysfunction - Known thyroid antibody positivity or presence of goiter - History of head/neck radiation or thyroid surgery - Age > 30 - Type 1 diabetes or other autoimmune disorders - History of pregnancy loss, preterm delivery or infertility - 2 or more prior pregnancies - Family history of autoimmune thyroid disease or thyroid dysfunction - Morbid obesity (BMI >= 40) - Use of amiodarone, lithium, or recent administration of iodinated contrast - Residing in an area of known moderate - severe iodine insufficiency *Visual: Bullet list of 10 risk factors for targeted screening; no chart.* --- ## S37 — Women with overt and/or subclinical disease in pregnancy missed with targeted screening **Shown:** 21:06–21:14 **Detected states:** 21:10 **Keyframe:** `keyframes/kf_0048_002110.png` ### State 48 @ 21:10 - y-axis 0%-100%; 12 vertical bars with no value labels - x-axis studies: Vaidya et al. 2007 [142]; Horacek et al. 2010 [143]; Jiskra et al. 2011 [144]; Chang et al. 2013 [145]; Akafajsi et al. 2013 [146]; Goel et al. 2012 [147]; Altomare et al. 2013 [148]; Kian et al. 2013 [149]; Granfors et al. 2014 [151]; Ahmed et al. 2014 [152]; Nazarpour et al. 2016 [153]; Akram et al. 2017 [154] *Visual: Vertical bar chart (y-axis 0-100%): 12 bars, no numbers printed, roughly 15-90%; x-axis lists 12 studies: Vaidya et al. 2007 [142], Horacek et al. 2010 [143], Jiskra et al. 2011 [144], Chang et al. 2013 [145], Akafajsi et al. 2013 [146], Goel et al. 2012 [147], Altomare et al. 2013 [148], Kian et al. 2013 [149], Granfors et al. 2014 [151], Ahmed et al. 2014 [152], Nazarpour et al. 2016 [153], Akram et al. 2017 [154] (some x labels partly unreadable - see report).* *Note: some x-axis study labels are small/blurred - see report for uncertainty* --- ## S38 — Where We Are Today: Prevalence of Universal Screening Practices **Shown:** 21:14–21:29 **Detected states:** 21:21 **Keyframe:** `keyframes/kf_0049_002121.png` ### State 49 @ 21:21 - y-axis 0%-100%, x-axis years - 2004 Maine Survey ~48% - 2009 ACOG Survey ~13% - 2010 European Survey ~42% - 2012 ATA Survey ~73% - 2013 Latin America, Asian and East Asian Surveys ~28% - 2014 Brazilian Survey ~83% - 2016 Israeli Survey ~62% *Visual: Vertical bar chart (y-axis 0-100%) by year: 2004 Maine Survey ~48%, 2009 ACOG Survey ~13%, 2010 European Survey ~42%, 2012 ATA Survey ~73%, 2013 Latin America, Asian and East Asian Surveys ~28%, 2014 Brazilian Survey ~83%, 2016 Israeli Survey ~62%.* *Note: percentages read approximately from bar heights - see report* --- ## S39 — SUMMARY **Shown:** 21:29–21:50 **Detected states:** 21:40 **Keyframe:** `keyframes/kf_0050_002140.png` ### State 50 @ 21:40 - 1. Overt thyroid disease is an important health problem in pregnancy - 2. Simple and reliable screening tests are available - 3. Untreated overt disease causes demonstratable harms - 4. Effective treatment is available for these conditions - 5. Targeted screening misses a significant number of women needing treatment - 7. Universal screening has been shown to be cost-effective - 8. A large proportion of providers already do universal screening *Visual: Bulleted summary, numbered 1-8 with number 6 missing on the slide (jump from 5 to 7); no chart.* *Note: slide numbering skips 6 (as printed; 'demonstratable' is the slide spelling)* --- ## S40 — (slide) **Shown:** 21:50–21:56 **Detected states:** 21:53 **Keyframe:** `keyframes/kf_0051_002153.png` ### State 51 @ 21:53 - *(no text on screen)* *Visual: Red slide with a photo of white gulls perched along a black metal fence; joke following the screening-criteria theme.* --- ## S11 — Select your presentation **Shown:** 22:00–22:18 **Detected states:** 04:55, 22:10, 35:52, 40:51, 55:33, 57:58 **Keyframe:** `keyframes/kf_0052_002210.png` ### State 52 @ 22:10 - Select your presentation - My Files - Change Session - La Nouvelle B - Endocrine Debate Thyroid Dis... *Visual: Menu screen; the 'Alex Stagnaro-Green 11:45 AM - 12:45 PM' card is highlighted/selected with Start and My Files buttons.* --- ## S41 — Thyroid Disease in Pregnancy: To Screen or Not to Screen - AGAINST the MOTION **Shown:** 22:23–22:42 **Detected states:** 22:33 **Keyframe:** `keyframes/kf_0053_002233.png` ### State 53 @ 22:33 - Endocrine Debate - Thyroid Disease in Pregnancy: To Screen or Not to Screen - AGAINST the MOTION - Kristien Boelaert - Reader in Endocrinology - Consultant Endocrinologist - University of Birmingham - k.boelaert@bham.ac.uk *Visual: Boelaert title slide: ENDO 2019 banner top-left; University of Birmingham and IMSR logos top-right; three photos of Birmingham buildings along the bottom.* --- ## S42 — Disclosure **Shown:** 22:42–22:46 **Detected states:** 22:44 **Keyframe:** `keyframes/kf_0054_002244.png` ### State 54 @ 22:44 - Nothing to disclose *Visual: Mostly white slide with only the title and the sentence 'Nothing to disclose'; ENDO 2019 banner bottom-left; ENB/AACE-style flower graphics bottom-right.* --- ## S43 — (1) Thyroid dysfunction in pregnancy **Shown:** 22:46–23:15 **Detected states:** 23:01, 23:39 **Keyframe:** `keyframes/kf_0055_002301.png` ### State 55 @ 23:01 - Increased maternal total T4 and total T3 - Declining free T4 and free T3 with advancing gestation - TSH, TBG, Estrogen, HCG - Placental development and D3 metabolism - Fetal development - Physiological changes during pregnancy - Chan and Boelaert Clin Endo 2015 82: 313-326 - Korevaar et al. Nature Reviews 2017 13: 610-622 - Taylor et al. Frontiers in Endocrinology 2018 9: 1-7 *Visual: Physiology diagram: central pregnant-woman silhouette with arrows labelled TSH, TBG, Estrogen, HCG, maternal thyroxine (T4); boxes 'Increased maternal total T4 and total T3' and 'Declining free T4 and free T3 with advancing gestation'; labels 'Placental development and D3 metabolism', 'Fetal development'; title above diagram 'Physiological changes during pregnancy'.* ### State 56 @ 23:39 - Increased maternal total T4 and total T3 - Declining free T4 and free T3 with advancing gestation - Overt Hypothyroidism: High TSH low FT4 0.2-0.6% - Overt Hyperthyroidism: Low TSH high FT4 0.2-0.4% - Subclinical Hypothyroidism: High TSH normal T4 2-18% - Isolated Hypothyroxinemia: Normal TSH low FT4 ~2% - Transient Gestational Thyrotoxicosis 1-3% - Chan and Boelaert Clin Endo 2015 82: 313-326 - Korevaar et al. Nature Reviews 2017 13: 610-622 - Taylor et al. Frontiers in Endocrinology 2018 9: 1-7 *Visual: Physiology diagram: central pregnant-woman silhouette with arrows labelled TSH, TBG, Estrogen, HCG, maternal thyroxine (T4); boxes 'Increased maternal total T4 and total T3' and 'Declining free T4 and free T3 with advancing gestation'; labels 'Placental development and D3 metabolism', 'Fetal development'; title above diagram 'Physiological changes during pregnancy'.* *Note: incremental build: right-hand prevalence column added* --- ## S44 — (1) Thyroid autoimmunity in pregnancy **Shown:** 24:02–24:52 **Detected states:** 24:28, 25:04 **Keyframe:** `keyframes/kf_0057_002428.png` ### State 57 @ 24:28 - TPO abs: 5-14% of unselected pregnancies (10-30% in subfertile/recurrent miscarriage population) - TABLET Trial: 9.5% TPO-positive (N = 19,237 screened) - TPO status affects treatment thresholds for starting levothyroxine - Korevaar et al. JCEM 2017 102: 69-77 *Visual: Bullet slide (3 bullets); citation Korevaar et al. JCEM 2017; in the later state 4 small line charts appear (see per-state note).* ### State 58 @ 25:04 - TPO abs: 5-14% of unselected pregnancies (10-30% in subfertile/recurrent miscarriage population) - TABLET Trial: 9.5% TPO-positive (N = 19,237 screened) - TPO status affects treatment thresholds for starting levothyroxine - 4 line charts: FT4 in pmol/L and TSH in mIU/L vs hCG in IU/L, for TPOAb negative vs positive; p<0.0001 for FT4/TSH decline in negatives, p=0.79 / p=0.92 in positives. - Korevaar et al. JCEM 2017 102: 69-77 *Visual: Bullet slide (3 bullets); citation Korevaar et al. JCEM 2017; in the later state 4 small line charts appear (see per-state note).* *Note: incremental build: 4 charts added below bullets* --- ## S45 — (2) Screening tool: TFT and TPO testing **Shown:** 25:16–26:24 **Detected states:** 25:50 **Keyframe:** `keyframes/kf_0059_002550.png` ### State 59 @ 25:50 - Interpretation of thyroid function tests not straightforward - Use of gestation-specific reference ranges recommended - not readily available - Continued debate and changes on "normal reference ranges" - Reference ranges derived from cross-sectional samples not considering longitudinal trajectories - FT4 concentration measurements often problematic *Visual: Red bullet slide (5 bullets); no chart.* --- ## S46 — (3) Intervention favorably influences disease? - CATS TRIAL **Shown:** 26:24–27:11 **Detected states:** 26:48 **Keyframe:** `keyframes/kf_0060_002648.png` ### State 60 @ 26:48 - CATS TRIAL - Treatment of sub. hypothyroidism or hypothyroxinemia with 150ug LT4 - Start treatment median week 13, IQ test at age 3 years - Mean offspring IQ: LT4 99.2 | Placebo 100.0 | Difference -0.8 | P 0.40 | (N/groups) (323/326) - No differences in obstetric outcomes - Lazarus et al. N Engl J Med. 2012 366: 493-5 *Visual: Table 'Mean offspring IQ': LT4 | Placebo | Difference | P | (N/groups); row Subcl. Hypo OR Hypothyroxinemia 99.2 | 100.0 | -0.8 | 0.40 | (323/326); note 'No differences in obstetric outcomes'.* --- ## S47 — (3) Intervention favorably influences disease - NICHD TRIAL **Shown:** 27:11–27:42 **Detected states:** 27:26 **Keyframe:** `keyframes/kf_0061_002726.png` ### State 61 @ 27:26 - NICHD TRIAL - Treatment of women with sub. hypothyroidism (100ug LT4) or hypothyroxinemia (50ug LT4) - Mean treatment start week 17, IQ test age 3/5 yrs - Powered to detect a 5 point IQ difference - Mean offspring IQ - Subclinical hypothyroidism: LT4 97 | Placebo 94 | Difference +3 | P 0.71 | (323/326) - Mean offspring IQ - Hypothyroxinemia: LT4 94 | Placebo 91 | Difference +3 | P 0.30 | (254/253) - No differences in obstetric outcomes - Casey et al. N Engl J Med 2017 376: 815-25 *Visual: Table 'Mean offspring IQ': LT4 | Placebo | Difference | P | (N/groups); rows Subclinical hypothyroidism 97 | 94 | +3 | 0.71 | (323/326); Hypothyroxinemia 94 | 91 | +3 | 0.30 | (254/253); note 'No differences in obstetric outcomes'.* --- ## S48 — (3) Intervention favorably influences disease - TABLET results **Shown:** 27:42–28:19 **Detected states:** 28:00 **Keyframe:** `keyframes/kf_0062_002800.png` ### State 62 @ 28:00 - Primary outcome - Livebirth >=34 weeks: Levothyroxine 176/470 (37.4%) | Placebo 178/470 (37.9%) | Comparison 0.97 (0.83, 1.14) | p=0.74 - Secondary pregnancy outcomes (as a proportion of women who achieved pregnancy within 12 months; N=266 vs N=274): - Clinical pregnancy at 7 weeks: 237/266 (89.1%) vs 248/274 (90.5%); 0.98 (0.93, 1.04) - On-going pregnancy at 12 weeks: 194/266 (72.9%) vs 200/274 (73.0%); 1.00 (0.90, 1.11) - Miscarriage <24 weeks: 75/266 (28.2%) vs 81/274 (29.6%); 0.95 (0.73, 1.23) - Livebirth >=34 weeks: 176/266 (66.2%) vs 178/274 (65.0%); 1.02 (0.90, 1.15) - Dhillon-Smith et al. N Engl J Med 2019: epub *Visual: Table: Outcome | Levothyroxine | Placebo | Comparison; primary outcome Livebirth >=34 weeks 176/470 (37.4%) vs 178/470 (37.9%), 0.97 (0.83, 1.14), p=0.74 (red oval highlights this row); secondary pregnancy outcomes (N=266 vs N=274): clinical pregnancy at 7 weeks 237/266 (89.1%) vs 248/274 (90.5%) 0.98 (0.93, 1.04); on-going pregnancy at 12 weeks 194/266 (72.9%) vs 200/274 (73.0%) 1.00 (0.90, 1.11); miscarriage <24 weeks 75/266 (28.2%) vs 81/274 (29.6%) 0.95 (0.73, 1.23); livebirth >=34 weeks 176/266 (66.2%) vs 178/274 (65.0%) 1.02 (0.90, 1.15).* --- ## S49 — (3) Intervention favorably influences disease - TABLET subgroup forest plot **Shown:** 28:19–28:42 **Detected states:** 28:31 **Keyframe:** `keyframes/kf_0063_002831.png` ### State 63 @ 28:31 - Subgroups: maternal age (<35, >=35 yr); No. of previous miscarriages (0, 1 or 2, >=3); Thyrotropin concentration at baseline (<=2.5, >2.5 mIU/liter); Infertility treatment at time of randomization (Yes/No); Thyroid peroxidase antibody concentration at baseline (Low/High); Race or ethnic group (White, South Asian, Chinese/black/other); BMI (<25, >=25) - All participants: Levothyroxine 176/470 vs Placebo 178/470; Relative Risk 0.97 (0.83-1.14); P for interaction 0.74 - Relative risk axis 0.50 / 0.75 / 1.00 / 1.50 / 2.50 with 'Placebo Better' and 'Levothyroxine Better' - Dhillon-Smith et al. N Engl J Med 2019: epub *Visual: Forest plot of relative risk (95% CI) by subgroup (maternal age, number of previous miscarriages, thyrotropin concentration at baseline <=2.5 vs >2.5 mIU/L [highlighted row], infertility treatment, TPO antibody, race/ethnic group, BMI) plus 'All participants' 176/470 vs 178/470, 0.97 (0.83-1.14), p interaction 0.74; axis 0.50-2.50 with 'Placebo Better' / 'Levothyroxine Better'.* *Note: dense table - subgroup rows condensed; individual cell values omitted* --- ## S50 — (3) Intervention favorably influences disease - TABLET trial (survival curve) **Shown:** 28:42–29:22 **Detected states:** 29:02 **Keyframe:** `keyframes/kf_0064_002902.png` ### State 64 @ 29:02 - TABLET trial - line graph: Pregnancy (%) (0-100%) vs Weeks from Conception to Pregnancy End; two nearly identical curves (Levothyroxine, Placebo); number-at-risk table below (Levothyroxine 470, 324, 310, 301, 255, ...; Placebo 470, 324, 303, 291, 242, ...) - Dhillon-Smith et al. N Engl J Med 2019: epub *Visual: Line graph: pregnancy (%) y-axis 0-100% vs weeks from conception to pregnancy end; two nearly overlapping lines (Levothyroxine blue, Placebo pink); below the axis a 'number at risk' table (Levothyroxine/Placebo rows, ~470 starting) with counts at 0,3,6,9,12,15,20,25,30,35,40,45+ weeks.* *Note: number-at-risk values approximate - see report* --- ## S51 — (3) Intervention may cause harm - optimal vs overtreatment **Shown:** 29:22–30:30 **Detected states:** 29:56 **Keyframe:** `keyframes/kf_0065_002956.png` ### State 65 @ 29:56 - c Optimal treatment scenario - d Overtreatment scenario - y-axis: Mean cortex volume (cm3) 530-550 - x-axis: Maternal free T4 (pmol/l) - 7.4, 12.2, 20.1, 33.1, 54.6 - Shaded normal range band; blue fitted curve with pink observed points; overtreatment curve declines steeply at high maternal free T4 - Korevaar et al. Nature Reviews 2017 13: 610-622 *Visual: Two line graphs (c 'Optimal treatment scenario', d 'Overtreatment scenario'): y-axis Mean cortex volume (cm3) 530-550, x-axis Maternal free T4 (pmol/l) 7.4, 12.2, 20.1, 33.1, 54.6; shaded 'Normal range' band; blue fitted curve with pink observed points; the overtreatment curve declines at high fT4.* --- ## S52 — (3) Intervention may cause harm - FT4 >97.5th percentile and verbal IQ **Shown:** 30:30–31:46 **Detected states:** 31:08 **Keyframe:** `keyframes/kf_0066_003108.png` ### State 66 @ 31:08 - FT4 >97.5th percentile - INMA: High FT4 n=31, Reference n=628, beta -0.1 (-3.6, 3.7) - Generation R: n=78 vs 1,569, beta -2.4 (-5.8, 1.1) - ALSPAC: n=61 vs 1,162, beta -0.1 (-3.6, 3.3) - Overall: n=170 vs 3,359, beta -0.8 (-2.9, -1.2) - Forest plot: Lower verbal IQ <-> Higher verbal IQ - Right chart: Adjusted mean difference in verbal IQ (95% CI) vs Free T4 (pmol/L) categories <10.0, 10.0-10.99, 11.0-11.99, 12.0-12.99, 13.0-18.99, 19.0-19.99, >20.0 - Increased risk of ADHD in proportion of women overtreated in CATS (unpublished) - High fT4 associated with autism in offspring - Levie et al. JCEM 2018 103: 2967-2979 - Andersen et al. Thyroid 2018; 28: 537-546 *Visual: Left table: Cohort | High FT4 (n) | Reference (n) | beta (95% CI); INMA 31/628 -0.1 (-3.6, 3.7); Generation R 78/1,569 -2.4 (-5.8, 1.1); ALSPAC 61/1,162 -0.1 (-3.6, 3.3); Overall 170/3,359 -0.8 (-2.9, -1.2), with forest plot 'Lower verbal IQ / Higher verbal IQ'. Right: adjusted mean difference in verbal IQ (95% CI) by free T4 category (<10.0, 10.0-10.99, 11.0-11.99, 12.0-12.99, 13.0-18.99, 19.0-19.99, >20.0 pmol/l).* --- ## S53 — (3) Intervention may cause harm - Maraka adverse outcomes table **Shown:** 31:46–32:25 **Detected states:** 32:06 **Keyframe:** `keyframes/kf_0067_003206.png` ### State 67 @ 32:06 - Pregnancy loss: 89 (10.6) vs 614 (13.5); Unadjusted 0.76 (0.60 to 0.96); Adjusted 0.62 (0.48 to 0.82); P 0.01 - Preterm delivery: 60 (7.1) vs 236 (5.2); 1.41 (1.05 to 1.88); 1.60 (1.14 to 2.24); 0.01 - Preterm labor: 111 (13.2) vs 569 (12.5); 1.08 (0.87 to 1.34); 1.14 (0.89 to 1.46); 0.29 - Premature rupture of membranes: 42 (5.0) vs 220 (4.8); 1.04 (0.74 to 1.45); 0.97 (0.66 to 1.42); 0.87 - Placental abruption: 7 (0.8) vs 36 (0.8); 1.05 (0.47 to 2.37); 1.60 (0.65 to 3.93); 0.30 - Gestational diabetes: 101 (12.0) vs 401 (8.8); 1.41 (1.12 to 1.78); 1.37 (1.05 to 1.79); 0.02 - Gestational hypertension: 49 (5.8) vs 221 (4.8); 1.24 (0.90 to 1.70); 1.27 (0.88 to 1.82); 0.21 - Pre-eclampsia: 46 (5.5) vs 177 (3.9); 1.43 (1.03 to 2.00); 1.61 (1.10 to 2.37); 0.01 - Poor fetal growth: 78 (9.3) vs 397 (8.7); 1.07 (0.83 to 1.38); 1.12 (0.84 to 1.50); 0.45 - Tachycardia: 18 (2.1) vs 90 (2.0); 1.08 (0.65 to 1.81); 1.77 (1.00 to 3.11); 0.05 - Maraka et al. BMJ 2017, 356: i6865 *Visual: Table: No. (%) events for thyroid hormone treatment (n=843) vs no thyroid hormone treatment (n=4562); Odds ratio (95% CI) unadjusted and adjusted; P value; outcomes pregnancy loss (89 (10.6) vs 614 (13.5); 0.76 (0.60 to 0.96); 0.62 (0.48 to 0.82); 0.01), preterm delivery (60 (7.1) vs 236 (5.2); 1.41 (1.05 to 1.88); 1.60 (1.14 to 2.24); 0.01), preterm labor, premature rupture of membranes, placental abruption, gestational diabetes (101 (12.0) vs 401 (8.8); 1.41 (1.12 to 1.78); 1.37 (1.05 to 1.79); 0.02), gestational hypertension, pre-eclampsia (46 (5.5) vs 177 (3.9); 1.43 (1.03 to 2.00); 1.61 (1.10 to 2.37); 0.01), poor fetal growth, tachycardia; several rows outlined in red.* --- ## S54 — (4) Cost-effectiveness **Shown:** 32:25–33:16 **Detected states:** 32:51, 33:26 **Keyframe:** `keyframes/kf_0068_003251.png` ### State 68 @ 32:51 - Economic model demonstrating incremental cost-effectiveness ratio of 7258 USD per QUALY - Based on 2 small RCT in area of mild iodine deficiency - Overall costs of personnel training, public education, establishment of healthcare infrastructure - Burden of over-diagnosis and over-treatment *Visual: Bullet slide (4 bullets); later state adds a pasted image of Munch's 'The Scream' with the label 'Anxiety and inconvenience for patients'.* ### State 69 @ 33:26 - Economic model demonstrating incremental cost-effectiveness ratio of 7258 USD per QUALY - Based on 2 small RCT in area of mild iodine deficiency - Overall costs of personnel training, public education, establishment of healthcare infrastructure - Burden of over-diagnosis and over-treatment - Anxiety and inconvenience for patients *Visual: Same bullet slide plus a pasted image of Munch's 'The Scream' with the label 'Anxiety and inconvenience for patients'.* *Note: incremental build: painting + label added* --- ## S55 — (5) No agreed policy on whom to treat - ATA 2017 Guidance **Shown:** 33:34–33:47 **Detected states:** 33:41, 34:12 **Keyframe:** `keyframes/kf_0070_003341.png` ### State 70 @ 33:41 - ATA 2017 Guidance: - Use trimester-specific reference ranges, similar assays or TSH > 4 mIU/L - Consider levothyroxine if TSH > 2.5 mIU/L in TPO+ or > 4.0 mIU/L in TPO- women - Don't routinely treat isolated hypothyroxinemia - Alexander et al. 2017 ATA guidelines, Thyroid 2017 27: 315-389 - Lazarus et al. 2014 ETA guidelines Eur Thyroid J 2014;3: 76-94 *Visual: Red slide with ATA 2017 Guidance bullets; later state adds a second green sub-heading 'ETA 2014 Guidance' with 3 more bullets.* ### State 71 @ 34:12 - ATA 2017 Guidance: - Use trimester-specific reference ranges, similar assays or TSH > 4 mIU/L - Consider levothyroxine if TSH > 2.5 mIU/L in TPO+ or > 4.0 mIU/L in TPO- women - Don't routinely treat isolated hypothyroxinemia - ETA 2014 Guidance: - Ideally trimester and population-specific ranges, otherwise (2.5 mIU/L, 3.0 mIU/L and 3.5 mIU/L in different trimesters - Treat SCH before and during pregnancy - Consider treatment of isolated hypothyroxinemia in 1st trimester - Alexander et al. 2017 ATA guidelines, Thyroid 2017 27: 315-389 - Lazarus et al. 2014 ETA guidelines Eur Thyroid J 2014;3: 76-94 *Visual: Red slide with ATA 2017 Guidance bullets; later state adds a second green sub-heading 'ETA 2014 Guidance' with 3 more bullets.* *Note: incremental build: ETA 2014 Guidance section added* --- ## S56 — Conclusions **Shown:** 34:37–35:48 **Detected states:** 35:13 **Keyframe:** `keyframes/kf_0072_003513.png` ### State 72 @ 35:13 - Criteria - Condition is common - V - Screening tool available, reliable, inexpensive and acceptable - X - Intervention favourably influences disease and does not cause harm - X - Screening and intervention cost-effective - X - Agreed upon policy on whom to treat - X - PREGNANT WOMEN SHOULD NOT UNDERGO UNIVERSAL SCREENING FOR THYROID FUNCTION AND THYROID ANTIBODIES *Visual: Table 'Criteria' with right-hand check/cross marks: Condition is common ✓; Screening tool available, reliable, inexpensive and acceptable ✗; Intervention favourably influences disease and does not cause harm ✗; Screening and intervention cost-effective ✗; Agreed upon policy on whom to treat ✗. Large green text: 'PREGNANT WOMEN SHOULD NOT UNDERGO UNIVERSAL SCREENING FOR THYROID FUNCTION AND THYROID ANTIBODIES'.* --- ## S11 — Select your presentation **Shown:** 35:48–35:55 **Detected states:** 04:55, 22:10, 35:52, 40:51, 55:33, 57:58 **Keyframe:** `keyframes/kf_0073_003552.png` ### State 73 @ 35:52 - Select your presentation - My Files - Change Session - La Nouvelle B - Endocrine Debate Thyroid Dis... *Visual: Menu screen; the 'Kristien Boelaert 11:45 AM - 12:45 PM' card is highlighted/selected.* --- ## S57 — Confusion on How to Monitor/Treat Women with SCH **Shown:** 36:02–38:22 **Detected states:** 37:12 **Keyframe:** `keyframes/kf_0074_003712.png` ### State 74 @ 37:12 - Confusion on How to Monitor/Treat Women with SCH - AVOID UNCERTAINTY AT ALL COSTS - Targeted Screening Yields SCH - Ethical Concept of Autonomy *Visual: Red slide: 'AVOID UNCERTAINTY AT ALL COSTS' plus a photo of an ostrich with its head buried in the sand; bottom lines 'Targeted Screening Yields SCH' and 'Ethical Concept of Autonomy'.* --- ## S58 — Subclinical Hyperthyroidism Correlation Studies **Shown:** 38:22–39:15 **Detected states:** 38:49 **Keyframe:** `keyframes/kf_0075_003849.png` ### State 75 @ 38:49 - Obstetrical Outcomes: No correlation - Casey et al. 2006, Rosario et al. 2016, Fraenkel et al. 2018 - Neonatal Outcomes: No correlation - Rosario et al. 2016, Fraenkel et al. 2018 - Decreased Offspring IQ/Cognitive Delay: Correlation found - Korevaar et al. 2015 | No correlation - Nelson et al. 2018, Pakkila et al. 2018 - Decreased risk of gestational hypertension: Correlation found - Casey et al. 2006 *Visual: Table: Outcome Studied | Correlation Found | No Correlation Found. Rows Obstetrical Outcomes (none | Casey 2006, Rosario 2016, Fraenkel 2018); Neonatal Outcomes (none | Rosario 2016, Fraenkel 2018); Decreased Offspring IQ/Cognitive Delay (Korevaar 2015 | Nelson 2018, Pakkila 2018); Decreased risk of gestational hypertension (Casey 2006).* --- ## S59 — Treatment of Graves' Disease - ATA Thyroid & Pregnancy Guidelines Recommendation 48 **Shown:** 39:15–39:56 **Detected states:** 39:35 **Keyframe:** `keyframes/kf_0076_003935.png` ### State 76 @ 39:35 - ATA Thyroid & Pregnancy Guidelines Recommendation 48 - "Antithyroid medication during pregnancy should be administered at the lowest effective dose of MMI or PTU, targeting maternal serum FT4/TT4 at or moderately above the reference range" - Strong Recommendation, High Quality Evidence *Visual: Quote slide: 'Antithyroid medication during pregnancy should be administered at the lowest effective dose of MMI or PTU, targeting maternal serum FT4/TT4 at or moderately above the reference range'; 'Strong Recommendation, High Quality Evidence'.* --- ## S60 — Screening Algorithm - Pre-conception or First Trimester **Shown:** 39:56–40:43 **Detected states:** 40:20 **Keyframe:** `keyframes/kf_0077_004020.png` ### State 77 @ 40:20 - Screening Algorithm - Pre-conception or First Trimester - TSH: Low <0.1 mIU/L -> Reflex fT4 - TSH: Normal 0.1-4.0 -> No Further Workup - TSH: High >4.0 mIU/L -> Reflex fT4 + TPO *Visual: Flowchart: green TSH box; Low (<0.1 mIU/L) -> yellow 'Reflex fT4'; Normal (0.1-4.0) -> red 'No Further Workup'; High (>4.0 mIU/L) -> yellow 'Reflex fT4 + TPO'.* --- ## S11 — Select your presentation **Shown:** 40:43–40:58 **Detected states:** 04:55, 22:10, 35:52, 40:51, 55:33, 57:58 **Keyframe:** `keyframes/kf_0078_004051.png` ### State 78 @ 40:51 - Select your presentation - My Files - Change Session - La Nouvelle B - Endocrine Debate Thyroid Dis... *Visual: Menu screen; the 'Alex Stagnaro-Green 11:45 AM - 12:45 PM' card is highlighted/selected and shows a 'Slides' button.* --- ## S61 — TABLET prevalence data **Shown:** 41:02–42:10 **Detected states:** 41:36 **Keyframe:** `keyframes/kf_0079_004136.png` ### State 79 @ 41:36 - Total number of women who had thyroid function tested n = 19,213 - Euthyroid n = 18,293 (95.2%) - Isolated Hypothyroxinaemia n = 46 (0.3%) - Overt thyroid dysfunction n = 85 (0.4%) - SC thyroid dysfunction n = 694 (3.6%) - Other n = 95 (0.5%) - Euthyroid subgroup TSH<2.5 n = 14,919 (77.7%); TSH 2.5-4.5 n = 3,374 (17.6%) - Overt Hypothyroid n = 36 (0.2%); Overt Hyperthyroid n = 49 (0.3%) - SC Hypo TSH>4.5 n = 451 (2.4%); SC Hyper n = 243 (1.3%) - TPOAb positive: 9.5% - SC Hypo TSH>=2.5 n = 3,825 (19.9%); Moderate SCH TSH 4.5-10 n = 421 (2.2%); Severe SCH TSH>10 n = 30 (0.2%) - Dhillon-Smith et al. N Engl J Med 2019: epub *Visual: Flowchart of participants: total n=19,213 tested -> Euthyroid n=18,293 (95.2%), Isolated Hypothyroxinaemia n=46 (0.3%), Overt thyroid dysfunction n=85 (0.4%), SC thyroid dysfunction n=694 (3.6%), Other n=95 (0.5%); Euthyroid subgroup TSH<2.5 n=14,919 (77.7%) / TSH 2.5-4.5 n=3,374 (17.6%); Overt Hypothyroid n=36 (0.2%); Overt Hyperthyroid n=49 (0.3%); SC Hypo TSH>4.5 n=451 (2.4%); SC Hyper n=243 (1.3%); TPOAb positive 9.5%; SC Hypo TSH>=2.5 n=3,825 (19.9%), Moderate SCH 4.5-10 n=421 (2.2%), Severe SCH >10 n=30 (0.2%).* --- ## S62 — CATS Results **Shown:** 42:10–42:49 **Detected states:** 42:29 **Keyframe:** `keyframes/kf_0080_004229.png` ### State 80 @ 42:29 - Overall: N 390 vs 404; Mean IQ (SD) 99.2 (13.3) vs 100.0 (13.3); difference 0.8 (-1.1 to 2.6); p 0.40; IQ<85 12.1% vs 14.1% (2.1% (-2.6 to 6.7%)) - Positive on TSH1: N 209 vs 219; 100.4 (13.7) vs 100.7 (13.0); 0.3 (-2.2 to 2.8); p 0.82; IQ<85 11.0% vs 13.7% - Positive on FT4?: N 204 vs 207; 97.8 (12.7) vs 99.2 (13.3); 1.3 (-1.3 to 3.8); p 0.28; IQ<85 13.2% vs 14.5% - Positive on TSH and FT4: N 23 vs 22; 97.7 (11.6) vs 99.4 (11.4); 1.7 (-5.2 to 8.6); p 0.61; IQ<85 13.0% vs 13.6% - Lazarus et al. N Engl J Med. 2012 366: 493-5 *Visual: Table of mean offspring IQ and IQ<85 by subgroup (Overall N=390/404, mean IQ 99.2 (13.3) / 100.0 (13.3), difference 0.8 (-1.1 to 2.6), p=0.40; Positive on TSH1 N=209/219 100.4 / 100.7, 0.3 (-2.2 to 2.8), p=0.82; Positive on FT4? N=204/207 97.8 / 99.2, 1.3 (-1.3 to 3.8), p=0.28; Positive on TSH and FT4 N=23/22 97.7 / 99.4, 1.7 (-5.2 to 8.6), p=0.61), with IQ<85 percentages; last subgroup outlined in red.* --- ## S63 — TABLET Results **Shown:** 42:49–54:41 **Detected states:** 48:45 **Keyframe:** `keyframes/kf_0081_004845.png` ### State 81 @ 48:45 - Levothyroxine | Placebo - No. of women withdrawn from trial medication due to abnormal TFT: 46 (9.8%) | 45 (9.6%) - No. of SAEs: 28 (5.9%) | 18 (3.8%) - No. of women with pre-eclampsia: 9 (5%) | 5 (3%) - No. of women with gestational diabetes: 20 (11%) | 16 (9%) - Dhillon-Smith et al. N Engl J Med 2019: epub *Visual: Two-column table: Levothyroxine | Placebo; rows No. of women withdrawn from trial medication due to abnormal TFT 46 (9.8%) vs 45 (9.6%); No. of SAEs 28 (5.9%) vs 18 (3.8%); No. of women with pre-eclampsia 9 (5%) vs 5 (3%); No. of women with gestational diabetes 20 (11%) vs 16 (9%).* --- ## S11 — Select your presentation **Shown:** 54:41–56:24 **Detected states:** 04:55, 22:10, 35:52, 40:51, 55:33, 57:58 **Keyframe:** `keyframes/kf_0082_005533.png` ### State 82 @ 55:33 - Select your presentation - My Files - Change Session - La Nouvelle B - Endocrine Debate Thyroid Dis... *Visual: Menu screen; the 'Alex Stagnaro-Green 11:45 AM - 12:45 PM' card is highlighted/selected (green arrow points at it).* --- ## S64 — Universal screening **Shown:** 56:28–57:00 **Detected states:** 56:44, 57:05 **Keyframe:** `keyframes/kf_0083_005644.png` ### State 83 @ 56:44 - It's cost-effective - Intervention does not cause harm - Screening tool is easy to use - There is an agreed treatment policy *Visual: Four portraits of UK political figures, each with an off-white speech bubble: 'It's cost-effective', 'Intervention does not cause harm', 'Screening tool is easy to use', 'There is an agreed treatment policy'; later state adds a photo of Theresa May with a thought bubble 'We must screen all pregnant women!'.* ### State 84 @ 57:05 - It's cost-effective - Intervention does not cause harm - Screening tool is easy to use - There is an agreed treatment policy - We must screen all pregnant women! *Visual: Same four politician speech-bubble portraits plus a photo of Theresa May with a white thought bubble 'We must screen all pregnant women!'.* *Note: incremental build: Theresa May + thought bubble added* --- ## S65 — Targeted case-finding **Shown:** 57:10–57:54 **Detected states:** 57:32 **Keyframe:** `keyframes/kf_0085_005732.png` ### State 85 @ 57:32 - Let's treat women who need Rx appropriately - Let's re-assess cost-effectiveness - Let's agree a policy - Let's conduct RCTs early in pregnancy *Visual: Photo of Michelle Obama at centre; four off-white thought bubbles around it: 'Let's treat women who need Rx appropriately', 'Let's re-assess cost-effectiveness', 'Let's agree a policy', 'Let's conduct RCTs early in pregnancy'.* --- ## S11 — Select your presentation **Shown:** 57:54–58:02 **Detected states:** 04:55, 22:10, 35:52, 40:51, 55:33, 57:58 **Keyframe:** `keyframes/kf_0086_005758.png` ### State 86 @ 57:58 - Select your presentation - My Files - Change Session - La Nouvelle B - Endocrine Debate Thyroid Dis... *Visual: Menu screen; the 'Kristien Boelaert 11:45 AM - 12:45 PM' card is highlighted/selected.* --- ## S06 — SESSION PARTICIPATION AND EVALUATIONS USING THE ENDO 2019 APP **Shown:** 58:05–58:12 **Detected states:** 03:45, 58:09 **Keyframe:** `keyframes/kf_0087_005809.png` ### State 87 @ 58:09 - STEP 1 Find the session - STEP 2 Tap the Participate Evaluate button - Complete session evaluations by clicking Evaluate This Session - Poll questions will appear once the speaker arrives to a question slide - Click on the question to respond - Click Ask to submit a question - END 2019 *Visual: Same ENDO 2019 app instructions slide, but the right-hand phone screenshot now shows the purple 'ENDO 2019' banner* *Note: near-duplicate of state 08 (same slide, slightly different app screenshot)* --- ## S07 — Question **Shown:** 58:12–58:26 **Detected states:** 03:57, 04:25, 58:20, 59:08 **Keyframe:** `keyframes/kf_0088_005820.png` ### State 88 @ 58:20 - 1. Are you in favor of screening all pregnant women for thyroid dysfunction? - – Yes - – No *Visual: Plain purple question slide; red banner at the bottom reads 'LIVE POLLING IS THE NEXT SLIDE'; green arrow pointer.* --- ## S08 — 1. Are you in favor of screening all pregnant women for thyroid dysfunction? **Shown:** 58:28–58:39 **Detected states:** 04:09, 04:37, 58:34, 59:19 **Keyframe:** `keyframes/kf_0089_005834.png` ### State 89 @ 58:34 - Yes - No - 6 (yellow countdown box, bottom-right) *Visual: White live-poll screen of the ENDO 2019 app: question at top, 'Yes'/'No' options, large yellow countdown box bottom-right showing '6'.* --- ## S09 — 1. Are you in favor of screening all pregnant women for thyroid dysfunction? **Shown:** 58:40–58:45 **Detected states:** 04:18, 04:44, 58:42, 59:28 **Keyframe:** `keyframes/kf_0090_005842.png` ### State 90 @ 58:42 - Yes 54% - No 46% - Poll is Locked *Visual: White live-poll results screen of the ENDO 2019 app: question at top, Yes/No rows with percentages and horizontal bars (yellow for Yes, green for No), grey label 'Poll is Locked' bottom-right.* --- ## S10 — 1. Are you in favor of screening all pregnant women for thyroid dysfunction? **Shown:** 58:47–59:04 **Detected states:** 58:56, 59:47 **Keyframe:** `keyframes/kf_0091_005856.png` ### State 91 @ 58:56 - Yes 71% (Pre-Test) / 55% (Post-Test) - No 29% (Pre-Test) / 45% (Post-Test) - Pre-Test | Post-Test toggle buttons *Visual: Live-poll comparison screen of the ENDO 2019 app on black background: Pre-Test / Post-Test toggle buttons, Yes/No rows with grey (pre-test) and blue (post-test) horizontal bars and percentages.* --- ## S07 — Question **Shown:** 59:04–59:12 **Detected states:** 03:57, 04:25, 58:20, 59:08 **Keyframe:** `keyframes/kf_0092_005908.png` ### State 92 @ 59:08 - 2. Are you in favor of screening all pregnant women for thyroid autoimmunity? - – Yes - – No *Visual: Plain purple question slide; red banner at the bottom reads 'LIVE POLLING IS THE NEXT SLIDE'; green arrow pointer.* --- ## S08 — 2. Are you in favor of screening all pregnant women for thyroid autoimmunity? **Shown:** 59:14–59:24 **Detected states:** 04:09, 04:37, 58:34, 59:19 **Keyframe:** `keyframes/kf_0093_005919.png` ### State 93 @ 59:19 - Yes - No - 6 (yellow countdown box, bottom-right) *Visual: White live-poll screen of the ENDO 2019 app: question at top, 'Yes'/'No' options, large yellow countdown box bottom-right showing '6'.* --- ## S09 — 2. Are you in favor of screening all pregnant women for thyroid autoimmunity? **Shown:** 59:24–59:32 **Detected states:** 04:18, 04:44, 58:42, 59:28 **Keyframe:** `keyframes/kf_0094_005928.png` ### State 94 @ 59:28 - Yes 11% - No 89% - Poll is Locked *Visual: White live-poll results screen of the ENDO 2019 app: question at top, Yes/No rows with percentages and horizontal bars (yellow for Yes, green for No), grey label 'Poll is Locked' bottom-right.* --- ## S10 — 2. Are you in favor of screening all pregnant women for thyroid autoimmunity? **Shown:** 59:34–01:00:01 **Detected states:** 58:56, 59:47 **Keyframe:** `keyframes/kf_0095_005947.png` ### State 95 @ 59:47 - Yes 35% (Pre-Test) / 11% (Post-Test) - No 65% (Pre-Test) / 89% (Post-Test) - Pre-Test | Post-Test toggle buttons *Visual: Live-poll comparison screen of the ENDO 2019 app on black background: Pre-Test / Post-Test toggle buttons, Yes/No rows with grey (pre-test) and blue (post-test) horizontal bars and percentages.*