Effects of Combined Vigorous Interval Training Program and Diet on Body Composition, Physical Fitness, and Physical Self-Perceptions Among Obese Adolescent Boys and Girls.

PURPOSE: This study examined the effects of a five-week intervention combining vigorous interval training (VIT) with diet among twenty-four obese adolescents. Fourteen girls and ten boys (aged 14-15) schooled in a pediatric rehabilitation center participated. METHODS: The VIT intensity was targeted and remained above 80% of maximal heart rate (HR) and over six kilocalories per minute. Pre- and postintervention measures were body composition (BMI, weight, body fat percentage), physical self-perceptions (PSP), physical fitness (6-min walking distance and work) and its associated physiological responses (HRpeak and blood lactate concentration). A series of two-way analyses of variance or covariance controlling for weight loss were used to examine the changes. RESULTS: Significant improvements were found in body composition, physical fitness and PSP (endurance, activity level, sport competence, global physical self-concept and appearance). In addition, boys presented higher levels of perceived strength and global physical self-concept than girls. Finally, there was a significant increase in perceived endurance, sport competence, and global physical self-concept in girls only. CONCLUSION: This five-week VIT program combined with diet represents an effective means for improving body composition, physical fitness, and PSP in obese adolescents, the effects on PSP being larger among girls.

Psycho-Physiological Responses of Obese Adolescents to an Intermittent Run Test Compared with a 20-M Shuttle Run.

Among the running field tests that measure aerobic fitness indirectly, the 20-m shuttle run test is the one most commonly used among obese youth. However, this back and forth running test induces premature cessation of exercise in this population. The present study aimed to examine the psycho-physiological responses of obese adolescents to an intermittent (15-15) progressive and maximal run test as compared with a continuous shuttle run test. Eleven obese adolescents (age: 14-15 years; BMI = 34.01 ± 5.30 kg·m-2) performed both tests. A two-way ANOVA examined the main effects of the running test, participant's sex, and their interaction on maximal aerobic performance (net exercise duration and final velocity), physiological values (heart rate, pulmonary oxygen uptake, respiratory exchange ratio and blood lactate concentration) and psychological responses (rating of perceived exertion, and physical self-perceptions). Oxygen uptake and heart-rate values at 9 km·h-1 were also compared. Compared with a 20-m shuttle run, the 15-15 test induced lower pulmonary oxygen uptake values at 9 km/h (28.3 ± 2.7 vs. 35.4 ± 2.7 ml·min-1·kg-1) and finished with higher maximal velocity and net exercise duration (566 ± 156 vs. 346 ± 156 s, p < 0.001), with no inter-test physiological difference. The 15-15 test also resulted in higher ratings of perceived exertion (16.0 ± 1.2 vs. 12.7 ± 1.6, p < 0.001) and improved perceived physical condition compared with the 20-m shuttle run (+1.4 ± 1.4 vs. +0.2 ± 1.0, p < 0.05). Both tests induced a maximal aerobic power of obese adolescents, but the 15-15 test provided a more progressive speed increment and longer exercise duration. The 15-15 test also elicited a significant improvement of perceived physical condition. In conclusion the 15-15 test can be considered a relevant field test for assessing the aerobic fitness of obese adolescents.

Racial Inequity in High-Risk Infant Follow-Up Among Extremely Low Birth Weight Infants.

BACKGROUND AND OBJECTIVES: High-risk infant follow-up programs (HRIFs) are a recommended standard of care for all extremely low birth weight (ELBW) infants to help mitigate known risks to long-term health and development. However, participation is variable, with known racial and ethnic inequities, though hospital-level drivers of inequity remain unknown. We conducted a study using a large, multicenter cohort of ELBW infants to explore within- and between-hospital inequities in HRIF participation. METHODS: Vermont Oxford Network collected data on 19 503 ELBW infants born between 2006 and 2017 at 58 US hospitals participating in the ELBW Follow-up Project. Primary outcome was evaluation in HRIF at 18 to 24 months' corrected age. The primary predictor was infant race and ethnicity, defined as maternal race (non-Hispanic white, non-Hispanic Black, Hispanic, Asian American, Native American, other). We used generalized linear mixed models to test within- and between-hospital variation and inequities in HRIF participation. RESULTS: Among the 19 503 infants, 44.7% (interquartile range 31.1-63.3) were seen in HRIF. Twenty six percent of the total variation in HRIF participation rates was due to between-hospital variation. In adjusted models, Black infants had significantly lower odds of HRIF participation compared with white infants (adjusted odds ratio, 0.73; 95% confidence interval, 0.64-0.83). The within-hospital effect of race varied significantly between hospitals. CONCLUSIONS: There are significant racial inequities in HRIF participation, with notable variation within and between hospitals. Further study is needed to identify potential hospital-level targets for interventions to reduce this inequity.

Follow-through care for high-risk infants during the COVID-19 pandemic: lessons learned from the Vermont Oxford Network.

OBJECTIVE: The COVID-19 pandemic has altered the delivery of follow-up care for high-risk infants. We performed an audit to characterize programmatic responses in a quality improvement network. STUDY DESIGN: We audited 43 North American-based follow-up programs of the Vermont Oxford Network Extremely Low Birth Weight Follow-up Study Group in October, 2020. Our electronic survey included yes/no, agree/disagree, and free text response items. RESULT: The response rate was 67.4%. Most programs altered capacity and the timing, frequency, or content of clinical assessments. Most perceived practice changes compromised their ability to ascertain infants' medical and developmental needs. There was a rapid uptake of telemedicine services. Despite challenges with implementation, many endorsed improved connectedness with families. CONCLUSION: Programs adapted rapidly to meet the needs of high-risk infants during the pandemic. Clinical operations, assessment procedures, and quality metrics will also need to evolve. Quality improvement study group collaboratives are well-positioned to coordinate such work.

Optimizing High-risk Infant Follow-up in Nonresearch-based Paradigms: The New England Follow-up Network.

OBJECTIVES: To establish the first regional quality improvement collaborative solely dedicated to follow-through care of high-risk infants after Neonatal intensive care unit (NICU) discharge and to characterize extremely low birth weight (ELBW) follow-up in New England. METHODS: Eleven of 14 follow-up programs in New England partnered with the Vermont Oxford Network (VON) ELBW project for an initial data collection project. We collected information about the health status and developmental outcomes of infants born ≤1,000 g or younger than 28 weeks 2014-2016 at the 18-24 months corrected for gestational age (CGA) follow-up visit. VON collected and compiled the data. RESULTS: Of 993 eligible infants, 516 (52.0%) had follow-up visits. The rehospitalization rate was 33.9%, mostly respiratory illness. Ninety-six children (19.3%) had weight less than 10th percentile and 44 (8.9%) had weight less than third percentile at 18-24 months. Only 170 (61.4%) children had recommended hearing screening after NICU discharge. Forty-six (9.1%) had cerebral palsy; 81 of the 441 infants that completed all 3 sections of the Bayley Scales of Infant Development, third edition (18.4%) had any composite score less than 70. Over half of the social and demographic data were missing. CONCLUSION: Most quality initiatives in neonatology stop at NICU discharge. This first project by the New England Follow-up Network showed a low rate for clinical follow-up. It demonstrated many opportunities to improve postdischarge follow-through specific to NICU-based care. Future projects will aim to improve the quality of follow-through services through collaborative learning, data sharing, and comparative outcomes.

Growth morbidity in extremely low birth weight survivors of necrotizing enterocolitis at discharge and two-year follow-up.

PURPOSE: The purpose of this study was to examine postnatal growth outcomes and predictors of growth failure at 18-24months corrected age among extremely low birth weight (ELBW) survivors of necrotizing enterocolitis (NEC) compared to survivors without NEC. METHODS: Data were collected prospectively on ELBW (22-27weeks gestation or 401-1000g birth weight) infants born 2000-2013 at 46 centers participating in the Vermont Oxford Network follow-up project. Severe growth failure was defined as <3rd percentile weight-for-age. RESULTS: There were 9171 evaluated infants without NEC, 416 with medical NEC, and 462 with surgical NEC. Rates of severe growth failure at discharge were higher among infants with medical NEC (56%) and surgical NEC (61%), compared to those without NEC (36%). At 18-24months follow-up, rates of severe growth failure decreased and were similar between without NEC (24%), medical NEC (24%), and surgical NEC (28%). On multivariable analysis, small for gestational age, chronic lung disease, severe intraventricular hemorrhage or cystic periventricular leukomalacia, severe growth failure at discharge, and postdischarge tube feeding predicted <3rd percentile weight-for-age at follow-up. CONCLUSIONS: ELBW survivors of NEC have higher rates of severe growth failure at discharge. While NEC is not associated with severe growth failure at follow-up, one quarter of ELBW infants have severe growth failure at 18-24months. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: II.

Severe neurodevelopmental disability and healthcare needs among survivors of medical and surgical necrotizing enterocolitis: A prospective cohort study.

PURPOSE: This study characterizes neurodevelopmental outcomes and healthcare needs of extremely low birth weight (ELBW) survivors of necrotizing enterocolitis (NEC) compared to ELBW infants without NEC. METHODS: Data were collected prospectively on neonates born 22-27weeks' gestation or 401-1000g at 47 Vermont Oxford Network member centers from 1999 to 2012. Detailed neurodevelopmental evaluations were conducted at 18-24months corrected age. Information regarding rehospitalizations, postdischarge surgeries, and feeding was also collected. "Severe neurodevelopmental disability" was defined as: bilateral blindness, hearing impairment requiring amplification, inability to walk 10 steps with support, cerebral palsy, and/or Bayley Mental or Psychomotor Developmental Index <70. Diagnosis of NEC required both clinical and radiographic findings. RESULTS: There were 9063 children without NEC, 417 with medical NEC, and 449 with surgical NEC evaluated. Significantly higher rates of morbidity were observed among infants with a history of NEC. Those with surgical NEC were more frequently affected across all outcome measures at 18-24months corrected age: 38% demonstrated severe neurodevelopmental disability, nearly half underwent postdischarge operations, and a quarter required tube feeding at home. CONCLUSION: At 18-24months, extremely low birth weight survivors of necrotizing enterocolitis were at markedly increased risk (p<0.001) for severe neurodevelopmental disability, postdischarge surgery, and tube feeding. LEVEL OF EVIDENCE: II (prospective cohort study with <80% follow-up rate).

Identification of Risk Factors for Elevated Neonatal Gentamicin Trough Concentrations.

OBJECTIVES: The objective of this study was to identify neonatal and maternal characteristics that may be associated with elevated neonatal gentamicin trough concentrations despite application of a previously published gentamicin dosage strategy. METHODS: Retrospective cohort study of all neonates admitted to University of Vermont Medical Center (562-bed academic teaching hospital, Burlington, VT) receiving gentamicin between June 1, 2009, and August 31, 2013. A total of 205 neonates were included, with 41 cases and 164 controls. RESULTS: Postmenstrual age (PMA, gestational age plus chronological age) and small-for-gestational age (SGA) status were independently associated with elevated neonatal gentamicin trough concentrations. No maternal risk factor evaluated remained significantly associated in the multivariate analysis. CONCLUSIONS: The probability of an elevated gentamicin trough concentration increases with lower PMA and is further accentuated in neonates with SGA status. In contrast, the presence of maternal risk factors did not increase the likelihood of elevated gentamicin trough concentrations. Neonates with lower PMA and SGA status may require an individualized dosage and monitoring strategy.

Decreased microvascular myogenic response to insulin in severely obese adolescents.

By means of flowmotion analysis, it is mainly accepted that, in normal conditions, insulin specifically increases the activity of microvascular smooth muscle. The objective of this study was to compare this effect in severely obese and normal-weight adolescents. Laser Doppler measurements were used to assess cutaneous blood flux (CBF) and flowmotion in response to transdermal iontophoresis of insulin in 20 severely obese adolescents (SOA) aged 12-17 years (BMI = 33.34 ± 1.07 kg/m2), and 16 normal-weight adolescents (BMI = 18.85 ± 0.50 kg/m2). Fasting insulin levels were higher in SOA than in normal-weight adolescents (6.25 ± 1.03 vs. 3.11 ± 0.28 µU/ml, P = 0.007). Net insulin-induced increase of CBF did not significantly differ between SOA and normal-weight adolescents (422.41 ± 146.09 vs. 232.36 ± 80.98 %, P = 0.265). A significant impairment of myogenic flowmotion was detected in SOA compared to normal-weight adolescents in response to insulin delivery (5.91 ± 0.35 vs. 8.12 ± 0.63 %, P = 0.003). Severely obese adolescents exhibit decreased myogenic activity in response to insulin, which may be an early step in the development of insulin resistance.

Effects of a lifestyle program on vascular reactivity in macro- and microcirculation in severely obese adolescents.

CONTEXT AND OBJECTIVE: This study aimed to comprehensively assess the macro- and microcirculation of severely obese adolescents (SOA) and normal-weight counterparts and to determine the longitudinal effects of weight loss on vascular function in SOA. DESIGN, SETTING, PARTICIPANTS, AND OUTCOME MEASURES: Seventeen SOA (body mass index z-score = 4.22 ± 0.73) and 19 puberty-matched normal-weight counterparts (body mass index z-score = -0.02 ± 1.04) were included. The SOA participated in a 4 month weight loss program. Brachial artery flow-mediated dilation and response to sublingual nitrate (nitrate-mediated dilation [NMD]) were assessed by high-resolution ultrasound. Microvascular reactivity was evaluated by laser Doppler flowmetry in response to NMD, iontophoresis of acetylcholine and sodium nitroprusside, and local hyperthermia. Plasma insulin, leptin, resistin, C-reactive protein, myeloperoxidase, and tissue plasminogen activator were measured. RESULTS: At baseline, SOA had similar flow-mediated dilation and impaired NMD in the brachial artery compared to normal-weight adolescents. Similarly, peak responses to acetylcholine and sodium nitroprusside iontophoresis and to local hyperthermia were unaltered, whereas cutaneous blood flow after NMD was lower in the forearm microcirculation of SOA. All plasma measurements were significantly higher in SOA. After the 4-month program, SOA presented a weight reduction of 7.4 ± 3.1%, but neither brachial artery nor microvascular reactivity variables were improved. Significant decreases were detected in plasma leptin, myeloperoxidase, and tissue plasminogen activator. CONCLUSIONS: Macro- and microvascular endothelial function are preserved in adolescents with severe obesity. Conversely, weight loss does not improve their impaired smooth muscle response to exogenous organic nitrate in both vascular beds, despite reducing plasma markers adversely related to vascular homeostasis.

APOB-516 T allele homozygous subjects are unresponsive to dietary changes in a three-month primary intervention study targeted to reduce fat intake.

Dietary guidelines aim to control fat intake and reduce cardiovascular risk but an important interindividual variability occurs among subjects. The objective was to investigate whether the response of lipid and glucose homeostasis parameters after a three-month diet aimed at reducing cardiovascular risk could be modulated by the -516C/T polymorphism in the apolipoprotein B gene (APOB). Middle-aged men (n = 69) and women (n = 100) with moderate cardiovascular disease risk were advised to reduce total energy and fat intakes and replace saturated dietary fat by monounsaturated and polyunsaturated fat. Subjects were genotyped for APOB-516C/T polymorphism. At the entry and at the end of the three-month period, fasting and postprandial plasma lipid analyses were performed. At entry, subjects homozygous for the APOB-516 T allele exhibited significantly lower fasting plasma concentrations of apolipoprotein B 48, triglycerides and triglyceride-rich lipoproteins-triglycerides compared to C carrier subjects. After the diet period, while C carrier subjects presented a clear improvement of most biological parameters, paradoxically T/T subjects did not modify them. In addition, the apoB 48 postprandial response after a standardized mixed test meal was not improved in T/T subjects after the three-month diet, contrary to C allele carriers. Even though their phenotype at entry does not show any significant increase of risk factors when compared to other groups, subjects homozygous for the APOB-516 T allele are unresponsive to a healthy diet that improves cardiovascular risk status in the whole population.

Neurodevelopmental outcome of extremely low birth weight infants from the Vermont Oxford network: 1998-2003.

BACKGROUND: Physicians and parents face significant uncertainties when making care decisions for extremely low birth weight (ELBW) infants. Many published estimates of death and developmental outcome are from well-funded university programs and may not reflect outcomes of infants from a variety of settings. The best estimates of the probabilities of death and severe disability combine local experience and published data. OBJECTIVE: To describe the neurodevelopmental outcome of ELBW infants from centers of the ELBW Infant Follow-Up Group of the Vermont Oxford Network (VON) and to identify characteristics associated with severe disability. METHODS: Predefined measures of living situation, health and developmental outcome were collected at 18-24 months' corrected age for infants born from July 1, 1998 to December 31, 2003 with birth weights of 401-1,000 g at 33 North American VON centers. Logistic regression was used to identify characteristics associated with severe disability. RESULTS: 6,198 ELBW infants were born and survived until hospital discharge; by the time of follow-up, 88 infants (1.4%) had died. Of the remaining 6,110 infants, 3,567 (58.4%) were evaluated. Severe disability occurred in 34% of the assessed infants. Multivariate logistic regression suggested cystic periventricular leukomalacia, congenital malformation and severe intraventricular hemorrhage were the characteristics most highly associated with severe disability. There were marked variations among the follow-up clinics in the attrition rate. CONCLUSION: ELBW infants completing evaluation were at a high risk for severe disability. There are considerable differences among participating centers in attrition at follow-up. Further resources will be needed to study the effect of follow-up care for this group of infants.

Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project.

OBJECTIVE: The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to healthy newborns during the birth hospitalization. METHODS: All Vermont hospitals with obstetric services participated. The quality-improvement collaborative (intervention) was based on the Breakthrough Series Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia; performance of metabolic and hearing screens; assessment of and counseling on tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to domestic violence; and planning for outpatient follow-up care. The effect of the intervention was assessed at the end of an 18-month period. Preintervention and postintervention chart audits were conducted by using a random sample of 30 newborn medical charts per audit for each participating hospital. RESULTS: Documented rates of assessment improved for breastfeeding adequacy (49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position (13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of counseling improved for tobacco smoke exposure (23% vs 53%) and car safety seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs 97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%), assessment of exposure to domestic violence (27% vs 36%), or planning for outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of > or = 20% in > or = 1 newborn preventive service. CONCLUSIONS: A statewide, hospital-based quality-improvement project targeting hospital staff members and community physicians was effective in improving documented newborn preventive services during the birth hospitalization.