Prehospital tele-electrocardiographic triage improves the management of acute coronary syndrome in rural populations: A systematic review and meta-analysis.

INTRODUCTION: Acute coronary syndrome (ACS) patients residing in rural areas are predisposed to higher risk of poor outcomes due to substantial delays in disease management, emphasising the importance of emerging telecardiology technologies in delivering emergency services in such settings. This meta-analysis aimed to investigate the impacts of prehospital telecardiology strategies on the clinical outcomes of rural ACS patients. METHODS: A literature search was performed of articles published up to April 2020 through six databases. Included studies were assessed for bias risk using the ROBINS-I tool, and a random-effects model was utilised to estimate effect sizes. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). RESULTS: Twelve studies with a total of 3989 patients were included in this review. Prehospital telecardiology in the form of tele-electrocardiography (tele-ECG) enabled prompt diagnosis and triage, resulting in a decreased door-to-balloon (DTB) time (mean difference = -25.53 minutes, 95% confidence interval (CI) -36.08 to -14.97 minutes; I2 = 98%), as well as lower in-hospital mortality (odds ratio (OR) = 0.57, 95% CI 0.36-0.92) and long-term mortality (OR = 0.52, 95% CI 0.39-0.69) rates, both with negligible heterogeneity (I2 = 0%). GRADE assessment yielded very low to moderate certainty of evidence.Conclusion Prehospital tele-ECG appeared to be an effective and worthwhile approach in the management of rural ACS patients, as shown by moderate quality evidence on lower long-term mortality. Given the uncertainties of the evidence quality on DTB time and in-hospital mortality, future studies with a higher quality of evidence are required to confirm our findings.

Laboratory comparison of stool processing methods for Xpert® Ultra.

TB disease diagnosis in children is difficult due to non-specific symptoms, paucibacillary disease and the need for invasive procedures to obtain diagnostic specimens. In many settings, these specimens are simply not collected and therefore stool, easily obtained, has emerged as a promising specimen for the diagnosis of child TB. In this study, stool from a healthy adult was spiked with known concentrations of bacille Calmette-Guérin vaccine and tested using the Xpert® Ultra assay to determine the relative detection and error rate associated with four different published stool processing methods.

Le diagnostic de TB maladie chez l'enfant est difficile en raison de la non spécificité de symptômes, de son caractère paucibacillaire et du besoin de procédures invasives pour obtenir des échantillons diagnostiques. Dans de nombreux contextes, ces échantillons ne sont tout simplement pas recueillis ; c'est pourquoi les selles, faciles à obtenir, sont apparus comme un échantillon prometteur pour le diagnostic de la TB de l'enfant. Dans cette étude, des selles d'un adulte en bonne santé ont été enrichies avec des concentrations connues de vaccin Bacille Calmette-Guérin et testés avec le test Xpert Ultra pour déterminer les taux relatifs de détection et d'erreur associés à quatre différentes méthodes publiées de traitement des selles.

Utilizing bi-spectral index (BIS) for the monitoring of sedated adult ICU patients: a systematic review.

BACKGROUND: The ideal level of sedation in the ICU is an ongoing source of scrutiny. At higher levels of sedation, the current scoring systems are not ideal. BIS may be able to improve both. We evaluated literature on effectiveness of BIS monitoring in sedated mechanically ventilated (MV) ICU patients compared to clinical sedation scores (CSS). METHODS: For this systematic review, full text articles were searched in OVID, MEDLINE, EMBASE, and Cochrane databases from 1986 - 2014. Additional studies were identified searching bibliographies/abstracts from national/international Critical Care Medicine conferences and references from searched articles retrieved. Search terms were: 'Clinical sedation scale, Bi-spectral Index, Mechanical ventilation, Intensive care Unit'. Included were prospective, randomized and non-randomized studies comparing BIS monitoring with any CSS in MV adult (>18 yr old) ICU patients. Studies were graded for quality of evidence based on bias as established by the GRADE guidelines. Additional sources of bias were examined. RESULTS: There were five studies which met inclusion criteria. All five studies were either unclear or high risk for blinding of participants and blinding of outcome assessment. All papers had at least one source of additional high risk, or unclear/unstated. CONCLUSIONS: BIS monitoring in the mechanically ventilated ICU patient may decrease sedative drug dose, recall, and time to wake-up. The studies suggesting this are severely limited methodologically. BIS, when compared to subjective CSSs, is not, at this time, clearly indicated. An appropriately powered randomized, controlled study is needed to determine if this monitoring modality is of use on the ICU.

Novel application of NIH case definitions in a paediatric tuberculosis contact investigation study.

BACKGROUND: International (National Institutes of Health [NIH]) case definitions have been proposed for paediatric tuberculosis (TB) diagnostic studies. The relevance of these definitions for contact tracing studies is unknown. METHODS: We developed case definitions for a community-based contact tracing diagnostic study. We compare disease certainty using protocol-defined and NIH case definitions and describe TB disease spectrum and severity. RESULTS: There were 111 potential disease episodes in 109 (21% human immunodeficiency virus [HIV] infected) of 1093 children enrolled. Based on NIH definitions, there were 8 confirmed, 12 probable, 17 possible and 3 unlikely TB and 2 non-TB episodes. Using protocol case definitions, there were 23 episodes of confirmed, 36 probable, 27 possible and 0 unlikely TB and 21 non-TB. Of 111 potential episodes, 69 were unclassifiable using the NIH definition, while 4 were unclassifiable using the protocol definition. Agreement between definitions was 0.30 (95%CI 0.23-0.38). There were 62 episodes (72%) of non-severe and 24 (28%) of severe TB. CONCLUSIONS: The NIH definition had limited applicability to household contact studies, despite the wide spectrum of disease observed. Further research is needed to develop case definitions relevant to different research settings, including contact investigation to capture the wide spectrum of paediatric TB in clinical research.

High-risk osteoporosis clinic (HiROC): improving osteoporosis and postfracture care with an organized, programmatic approach.

SUMMARY: A programmatic outpatient high-risk osteoporosis clinic (outpatient HiROC) and inpatient fracture liaison service (inpatient HiROC) is described. Results document that this population is more effectively treated and followed up in this specialty pathway than with primary care follow-up. INTRODUCTION: We describe a programmatic approach to outpatient care of high-risk osteoporosis patients (outpatient HiROC). We similarly describe an inpatient fracture liaison service (inpatient HiROC), which integrates into the existing outpatient HiROC pathway. METHODS: The development of outpatient HiROC and inpatient HiROC is described. Outpatient visits (July 29, 2008 to October 27, 2011) are included with a 200 patients random sample calculation. Inpatient consultation visits between November 18, 2008 and October 27, 2011 are included. RESULTS: Between July 29, 2008 and December 31, 2011, 1917 outpatient consults were seen. Of the 200 patient samples, 87% were female, mean age of 69.8 years, previous fractures occurred in 34% patients, and glucocorticoid users constituted 10.6%. Eighty-six percent of this group was high risk, where drug therapy is indicated, and such treatment was started in 89%. A total of 1041 inpatient fracture consults were seen during the evaluable period; 14.7% of this population died before the 6-month follow-up. Females comprised 77.6%, mean age was 76.1 years, and 58.2% of fractures were hip fragility, 11.6% vertebral, and 1.7% midshaft and 1.6% subtrochanteric. Patients seen in our outpatient HiROC pathway were significantly more likely to be treated than those followed up by one of our primary care doctors (80.6 versus 32.2%, P<0.0001). Mean vitamin D levels at baseline (27.0 ng/mL) improved to 34.6 ng/mL at 6-month follow-up (P<0.0001). CONCLUSIONS: Our outpatient and inpatient HiROC model is efficient and effective in risk stratifying and treating patients at high risk for fractures.

Well-quantified tuberculosis exposure is a reliable surrogate measure of tuberculosis infection.

SETTING: Cape Town, South Africa. OBJECTIVE: To develop a standardized, reliable measure of household tuberculosis (TB) exposure that considers child-specific risk factors. DESIGN: We assessed TB exposure in 536 children. Children were considered Mycobacterium tuberculosis infected if two of three tests of infection were positive. Principal component analysis identified a discrete set of components that collectively described exposure and contributed to a composite contact score. Logistic regression assessed the odds of having M. tuberculosis infection given increasing contact score while controlling for age and past TB treatment. RESULTS: Four components described 68% of data variance: 1) maternal TB and sleep proximity, 2) index case infectivity, 3) duration of exposure, and 4) exposure to multiple index cases. Components were derived from 10 binary questions that contributed to a contact score (range 1-10, median 5, 25th-75th interquartile range [IQR] 4-7). Among children aged 3 months to 6 years with household exposure, the odds of being M. tuberculosis-infected increased by 74% (OR 1.74, 95%CI 1.42-2.12) with each 1-point increase in the contact score. CONCLUSIONS: Well-quantified TB exposure is a good surrogate measure of M. tuberculosis infection in child household contacts in a high-burden setting, and could guide targeted preventive treatment in children at highest risk of M. tuberculosis infection.

Environmental tobacco smoke exposure increases Mycobacterium tuberculosis infection risk in children.

BACKGROUND: Data on the association between exposure to environmental tobacco smoke (ETS) and Mycobacterium tuberculosis infection in children are limited. OBJECTIVE: To examine the dose-response effect of ETS exposure on the risk of M. tuberculosis infection in children in a high tuberculosis (TB) burden setting. METHODS: This cross-sectional study included healthy South African children from impoverished urban communities. Data were collected on household ETS and M. tuberculosis exposure, demographics, socio-economic and anthropometric data, M. tuberculosis infection, human immunodeficiency virus and TB disease status. RESULTS: Among 196 children (median age 6.8 years, range 0.3-15.9), 97 (49.5%) were M. tuberculosis - i nfected (tuberculin skin test [TST] ≥ 10 mm) and 128 (65.3%) reported ETS exposure; of these, 81/128 (63.3%) were exposed to ≥ 2 household smokers. The presence of ≥ 2 household smokers was associated with M. tuberculosis infection in univariate analysis, irrespective of TST cut-off point. In analysis adjusting for M. tuberculosis exposure, socio-economic status, age and previous TB treatment, ETS exposure remained associated with M. tuberculosis infection. In univariate and multivariate analysis, pack-years of exposure were associated with risk of TB infection. DISCUSSION: Exposure to ETS is associated with M. tuberculosis infection in children after adjustment for multiple variables, with a dose-response relationship between the degree of ETS exposure and risk of infection. Public health interventions to reduce exposure to tobacco smoke among children in high TB burden settings are urgently needed.

Dental caries and enamel defects in very low birth weight adolescents.

OBJECTIVES: The purpose of this study was to examine developmental enamel defects and dental caries in very low birth weight adolescents with high risk (HR-VLBW) and low risk (LR-VLBW) compared to full-term (term) adolescents. METHODS: The sample consisted of 224 subjects (80 HR-VLBW, 59 LR-VLBW, 85 term adolescents) recruited from an ongoing longitudinal study. Sociodemographic and medical information was available from birth. Dental examination of the adolescent at the 14-year visit included: enamel defects (opacity and hypoplasia); decayed, missing, filled teeth of incisors and molars (DMFT-IM) and of overall permanent teeth (DMFT); Simplified Oral Hygiene Index for debris/calculus on teeth, and sealant presence. A caregiver questionnaire completed simultaneously assessed dental behavior, access, insurance status and prevention factors. Hierarchical analysis utilized the zero-inflated negative binomial model and zero-inflated Poisson model. RESULTS: The zero-inflated negative binomial model controlling for sociodemographic variables indicated that the LR-VLBW group had an estimated 75% increase (p < 0.05) in number of demarcated opacities in the incisors and first molar teeth compared to the term group. Hierarchical modeling indicated that demarcated opacities were a significant predictor of DMFT-IM after control for relevant covariates. The term adolescents had significantly increased DMFT-IM and DMFT scores compared to the LR-VLBW adolescents. CONCLUSION: LR-VLBW was a significant risk factor for increased enamel defects in the permanent incisors and first molars. Term children had increased caries compared to the LR-VLBW group. The effect of birth group and enamel defects on caries has to be investigated longitudinally from birth.

Mycobacterial genotype is associated with disease phenotype in children.

OBJECTIVE: To investigate the association between mycobacterial genotype and disease phenotype in children. METHODS: We describe hospitalised children diagnosed with culture-confirmed tuberculosis (TB) in South Africa, a high TB burden setting. Disease phenotype was classified as intrathoracic or extrathoracic based on mycobacterial culture site. Mycobacterial genotyping was completed using spoligotyping. RESULTS: We analysed 421 isolates from 392 children (median age 2 years, range 0.1-12). Intrathoracic disease was present in 294 (75%) children and extrathoracic disease in 98 (25%). The Beijing genotype was the most prevalent (32.9%), followed by the Latin American Mediterranean (LAM, 28.8%), and S genotypes (6.4%). Age was significantly associated with genotype. Children with the Beijing (OR = 2.36, 95%CI 1.21- 4.60) and S genotypes (OR = 3.47, 95%CI 1.26-9.56) were more likely to have extrathoracic disease compared to children infected with the LAM genotype, in analyses adjusted for age and drug resistance. CONCLUSIONS: TB genotype and disease phenotype in children were associated. Beijing and S genotypes were more frequently cultured from extrathoracic cultures, indicating potential improved ability to disseminate. Strain-related phenotypes could explain different disease spectra in geographic settings where certain strains are successful. Studies of mycobacterial human interaction should consider host immune responses, clinical and epidemiological factors.

Body mass index at the time of diagnosis and the risk of advanced stages and poorly differentiated cancers of the breast: findings from a case-series study.

INTRODUCTION: Obesity is a risk factor for postmenopausal breast cancer and is independently associated with shorter disease-free and overall survival. Currently, in clinical settings, the combination of stage and grade of cancer at the initial presentation of the disease is the best prognostic indicator. OBJECTIVE: To evaluate the association between body mass index (BMI) and risk of advanced stages and poorly differentiated grade of breast cancer. DESIGN: A case-series study of women diagnosed with their first primary invasive breast cancer. Patients include a total of 831 women aged >or=40 years with a mean BMI of 29.6(± 6.6) kg m(-2). Pathological, clinical and demographic data were retrieved from electronic medical records. Multinomial logistic regression analysis was preformed to estimate the risk of more advanced stages and poorly differentiated grade of cancer, adjusting for covariates. RESULTS: Obese compared with normal weight women had an 80% increased risk of cancer with more advanced stages (III/IV) and poorly differentiated grade (odds ratio = 1.80, 95% confidence interval 1.13-2.86, P = 0.014). No significant increase in risk was observed for overweight women. CONCLUSION: Obesity at the time of diagnosis of breast cancer is associated with more advanced stages and poorly differentiated grade of cancers.

Prospective comparison of radial and linear endoscopic ultrasound for diagnosis of chronic pancreatitis.

BACKGROUND AND STUDY AIMS: Linear endoscopic ultrasonography (EUS) is currently favored by many endosonographers for the evaluation of pancreatic pathology. However, radial EUS was used in early studies validating EUS for chronic pancreatitis. Radial and linear EUS have never been compared for the diagnosis of chronic pancreatitis. The aim of this study was to compare radial and linear EUS for the diagnosis of chronic pancreatitis using the secretin-stimulated endoscopic pancreatic function test (ePFT) as the reference standard. PATIENTS AND METHODS: One hundred consecutive patients evaluated for pain of possible pancreatic origin underwent combined radial EUS, linear EUS, and secretin ePFT during a single endoscopic session. EUS images were acquired on videotape and blindly scored by three reviewers. The main outcome measure was diagnostic accuracy. RESULTS: The accuracy of radial EUS and linear EUS (cutpoint > or = 4 criteria) was 84 % and 74 %, respectively. The statistical test for noninferiority was significant ( P < 0.001) suggesting that the accuracy of radial EUS is as good as or superior to linear EUS. The ratio of accuracy (pi (radial)/pi (linear)) was 1.14 (95 % confidence interval [CI] 0.99 to 1.28). No statistically significant differences were found between radial and linear EUS in terms of sensitivity, specificity, or overall discriminative ability (area under receiver operating characteristic curve 0.84 vs. 0.76, P = 0.10). Interobserver variability was similar for radial (Fleiss' kappa = 0.61, 95 %CI 0.43 to 0.79) and linear EUS (kappa = 0.50, 95 %CI 0.28 to 0.72). CONCLUSIONS: The accuracy of radial EUS is as good as linear EUS for the diagnosis of chronic pancreatitis.

Highly discordant T cell responses in individuals with recent exposure to household tuberculosis.

BACKGROUND: There are limited data comparing interferon-gamma release assays (IGRAs) for the detection of Mycobacterium tuberculosis infection in highly endemic settings. METHODS: A cross-sectional household contact study was conducted to measure the agreement of two IGRAs in relation to the tuberculin skin test (TST) to detect M tuberculosis infection and to assess the influence of M tuberculosis exposure and age. RESULTS: In 82 individuals in household contact, 93% of children and 42% of adults had a high M tuberculosis contact score. The TST was positive in 78% of adults and 54% of children, the T-SPOT.TB was positive in 89% of children and 66% of adults and the QuantiFERON TB Gold (QTF) was positive in a similar proportion of adults and children (38.1% and 39.6%). In children there was poor agreement between the TST and T-SPOT.TB (kappa = -0.15) and the T-SPOT.TB and the QTF (kappa = -0.03), but good agreement between the TST and the QTF (kappa = 0.78) using 10 mm cut-off. In adults there was fair to moderate agreement between the TST and T-SPOT.TB (kappa = 0.38), the TST and QTF (kappa = 0.34) and T-SPOT.TB and QTF (kappa = -0.50). High levels of exposure to M tuberculosis were associated with at least a sevenfold odds of being T-SPOT.TB positive (95% CI 7.67 to 508.69) and a threefold odds of being QTF positive (95% CI 3.02 to 30.54). There was a significant difference in the magnitude of T-SPOT.TB early secretory antigenic target (ESAT)-6 and culture filtrate protein 10 kD (CFP-10) spot counts between adults and children. CONCLUSIONS: The T-SPOT.TB may be more sensitive than the TST or QTF for detecting recent M tuberculosis infection in children. Differences between assays and the predictive utility of these findings for subsequent disease development should be prospectively assessed.

Older age does not increase risk of hemorrhagic complications after intravenous and/or intra-arterial thrombolysis for acute stroke.

BACKGROUND: The elderly have significantly higher incidence of ischemic stroke and have higher mortality and morbidity compared with younger patients. Intracranial hemorrhage (ICH) after thrombolysis is one of the causes of unfavorable outcome. However, it is unclear whether age over 80 years is a predictor for hemorrhagic transformation after intravenous, intra-arterial, or a combination of both thrombolytic therapies. METHODS: A database of 488 consecutive patients with ischemic stroke who received thrombolytic therapy was analyzed using logistic regression model to determine whether factors such as age over 80 years, demographic characteristics, onset to treatment time, severity of neurologic deficits, route of administration, blood glucose, or mean arterial pressure were associated with symptomatic ICH. RESULTS: The rates of symptomatic hemorrhage were 12.82% and 10.4% in older and younger groups, respectively. The odds of symptomatic hemorrhage after thrombolytic therapy for patients over 80 years of age after adjusting for route of administration, National Institutes of Health Stroke Scale score, mean arterial pressure, and glucose was not significantly different from that of the younger age group (odds ratio [OR] = 1.64; 95% confidence interval [CI]: 0.729-3.66). Hyperglycemia (>150 mg/dL) was associated with increased odds of symptomatic ICH (OR = 2.32; 95% CI: 1.09-4.93). Patients older than 80 years had similar rates of recanalization (OR = 0.8; 95% CI: 0.4-1.8) and rates of asymptomatic ICH (OR = 2.40; 95% CI: 0.89-6.5). CONCLUSIONS: Risks of ICH after thrombolysis for acute ischemic stroke are similar in patients over and under 80 years of age. Our data suggest that the decision to provide thrombolytic therapy should not be solely based on patient's age.

High level of discordant IGRA results in HIV-infected adults and children.

SETTING: Tygerberg district, Western Cape Province, South Africa. OBJECTIVE: To measure the agreement of two interferon-gamma release assays (IGRAs) and the tuberculin skin test (TST) for the detection of Mycobacterium tuberculosis infection in human immunodeficiency virus (HIV) infected adults and children in a setting highly endemic for tuberculosis (TB). DESIGN: Cross-sectional study. RESULTS: In HIV-infected adults (n=20) and children (n=23), tests yielded discordant results, with 61% of individuals testing positive with T-SPOT.TB, 41% with TST and 28% with QuantiFERON TB Gold (QTF). In children, there was poor agreement between the TST and T-SPOT.TB (kappa [kappa]=-0.02), but moderate agreement between the TST and QTF (kappa=0.44). In adults, there was moderate agreement between the TST and T-SPOT.TB (kappa=0.43), and the TST and QTF (kappa = 0.46). In children and adults, there was fair agreement between the T-SPOT.TB and QTF (kappa=0.33). Twenty per cent of adults had >or=1 indeterminate IGRA results. CONCLUSIONS: There is poor to moderate agreement between the TST and IGRAs in HIV-infected adults and children. T-SPOT.TB may have improved sensitivity for detection of M. tuberculosis infection in HIV-infected individuals compared to the QTF and the TST. In HIV-infected individuals, IGRA test properties are affected by test cut-off point and nil control responses.

Long-term sequelae of postnatal surfactant and corticosteroid therapies for BPD.

OBJECTIVE: This retrospective analysis assessed the relationship between medical treatment (postnatal steroids, surfactant) received neonatally and outcomes at 3 and 8 years using a longitudinal sample of children with bronchopulmonary dysplasia (BPD). STUDY DESIGN: Four groups were formed retrospectively based on the type of neonatal medical treatment received: no drug intervention (n=37), surfactant only (n=29), postnatal steroids only (n=13) and combined surfactant and postnatal steroids (n=16). Groups were compared on neurological and medical outcomes. RESULT: Combined postnatal steroids and surfactant treatment was associated with more days on supplemental oxygen than no intervention or surfactant only. Surfactant replacement therapy alone was not associated with adverse consequences; however, postnatal steroid exposure appeared to be related. CONCLUSION: Although retrospective analyses make statements about causation impossible, the differential relationships of therapies with cognitive outcomes argues for careful monitoring of therapeutic agents with very low birth weight infants.

Variation of cognition and achievement with sleep-disordered breathing in full-term and preterm children.

OBJECTIVE: Pediatric sleep-disordered breathing (SDB) has a disproportionately high prevalence in children who were preterm infants (preterm children) and is associated with behavioral comorbidity. Exposure to intermittent hypoxemia and sleep disruption may contribute to cognitive impairment. We quantified the association of SDB with cognition and achievement and determined whether preterm children are at a differentially increased risk for SDB-related impairments. DESIGN: Cross-sectional analyses. SETTING: Urban community. PARTICIPANTS: Eight hundred thirty-five children, aged 8 to 11 years.Intervention(s) None. MAIN OUTCOME MEASURES: Scores on the Peabody Picture Vocabulary Test-Revised, Kaufman Assessment Battery for Children, and Continuous Performance Test. RESULTS: One hundred sixty-four children had SDB. In unadjusted analyses, children with SDB had poorer scores on almost all tests of cognition and achievement. Group differences were attenuated after adjusting for socioeconomic status; in these analyses, children with SDB scored lower on the Peabody Picture Vocabulary Test-Revised (mean +/- SE score, 100.5 +/- 1.4 vs 103.6 +/- 0.7; P = .04), and the Kaufman Assessment Battery for Children riddles and triangles subscales. Associations were stronger in preterm than in full-term children. Of the sleep measures, snoring history was most strongly correlated with indices of cognition and achievement. CONCLUSIONS: Although moderate group differences were observed for almost all cognitive measures, an attenuation of effects was observed once socioeconomic status was considered. The deficits in selective measures of academic abilities, language comprehension, and planning and organizational skills suggest a negative impact of SDB on achievement and cognition. Stronger associations in preterm children suggest the importance of screening for snoring, a good predictor of cognitive function in this population.

Perinatal correlates and neonatal outcomes of small for gestational age infants born at term gestation.

OBJECTIVE: We sought to examine the current perinatal correlates and neonatal morbidity associated with intrauterine growth failure among neonates born at term gestation. STUDY DESIGN: We compared 372 small for gestational age (SGA, birth weight <10th percentile) infants born at term gestation to 372 appropriate for gestational age controls (AGA, birth weight 10th to 90th percentile) matched by sex, race, and gestational age within 2 weeks. RESULTS: Compared with AGA controls, significant (P < .05) maternal risk factors for SGA status included single marital status (59% versus 53%), lower prepregnancy weight (144 +/- 41 lbs versus 153 +/- 40 lbs), lower weight gain during pregnancy (29 +/- 15 lbs versus 33 +/- 15 lbs), smoking (25% versus 17%), hypertension (14% versus 7%), and multiple gestation (9% versus 2%). Mothers of SGA infants were more likely to undergo multiple (>or=3) antenatal ultrasound evaluations (19% versus 7%), biophysical profile monitoring (11% versus 4%), and oxytocin delivery induction (28% versus 16%) (P < .05). Pediatrician attendance was more common among SGA deliveries (50% versus 37%, P < .05). SGA infants had significantly higher rates of hypothermia (18% versus 6%) and symptomatic hypoglycemia (5% versus 1%). These neonatal problems remained significant even when medical or pathologic causes of intrauterine growth failure, including pregnancy hypertension, multiple gestation, and congenital malformations, were excluded. CONCLUSION: Despite higher rates of pregnancy complications among mothers of SGA infants, the rates of neonatal adverse outcomes are low. However, SGA infants remain at risk for hypothermia and hypoglycemia and require careful neonatal surveillance.

Immunization with Haemophilus influenzae type b-CRM(197) conjugate vaccine elicits a mixed Th1 and Th2 CD(4+) T cell cytokine response that correlates with the isotype of antipolysaccharide antibody.

Haemophilus influenzae type b (Hib) capsular polysaccharide (PS) induces protective antibodies but is T independent and poorly immunogenic in infants. Conjugate vaccines of Hib PS linked to proteins, such as CRM(197), increase the PS antibody titer and elicit immunologic memory. To define the conjugate-induced memory T cell response, 19 adults were immunized with Hib-CRM(197), and antibody titers, carrier protein-specific CD4(+) T cell proliferation, and cytokine production were measured. Hib-CRM(197) induced PS and CRM(197) antibodies, vigorous T cell recall responses, and production of cytokines, including interleukin (IL)-2, IL-5, IL-10, and interferon-gamma. There was marked variability in PS antibody titer, despite consistent CRM(197)-specific recall responsiveness, which correlated with peak IgM and IgA PS antibody titers. Correlations were also found between IL-2 and IL-5 and IgA PS antibody levels. Hib-CRM(197) induced a rapid increase in CRM(197)-specific memory T cells and mixed Th1/Th2 cytokines, which may regulate the isotype and quantity of PS antibody.

Patterns of fluoride intake from birth to 36 months.

OBJECTIVES: Dental fluorosis prevalence has increased in the United States, Canada, and other nations due to the widespread availability of fluoride in many forms, with fluoride ingestion during the first three years of life appearing most critical in fluorosis etiology. With few contemporary studies of fluoride ingestion in this age group, the purpose of this paper is to describe patterns of estimated fluoride ingestion from birth to 36 months of age from water, dentifrice, and dietary fluoride supplements and combined. METHODS: Repeated responses to separate series of questions about water intake, use of fluoride dentifrice, and use of fluoride supplements were collected by questionnaire as part of the longitudinal Iowa Fluoride Study and used to estimate fluoride intake. Estimated intake is reported by source and combined at different ages. Effects of subject age and other covariates on fluoride intake were assessed using regression methods appropriate for the analysis of correlated data. RESULTS: For most children, water fluoride intake was the predominant source, especially through age 12 months. Combined daily fluoride intake increased through 9 months, was lower at 12 and 16 months, and increased again thereafter. Mean intake per unit body weight (bw) was about 0.075 mg F/kg bw through 3 months of age, 0.06 mg F/kg bw at 6 and 9 months, 0.035 mg F/kg bw at 12 and 16 months, and 0.043 mg F/kg bw from 20-36 months. Depending on the threshold chosen (e.g., 0.05 or 0.07 mg F/kg bw), variable percentages of the children exceeded the levels, with percentages greatest during the first 9 months. Regression analyses showed fluoride intake (mg F/kg bw) from 1.5-9 months to decrease with increasing child's age, mother's age, and mother's education, with a complex three-way interaction among these factors. From 12-20 months, fluoride intake increased with increasing child age and decreased with increasing mother's age. No statistically significant relationships were found for fluoride intake from 24-36 months. CONCLUSIONS: There is considerable variation in fluoride intake across ages and among individuals. Longitudinal studies may be necessary to fully understand the relationships between fluoride ingestion over time and development of fluorosis.

Pacifier use and the occurrence of otitis media in the first year of life.

PURPOSE: The purpose of this study was to assess pacifier use as a risk factor for otitis media during the first year of life. METHODS: A volunteer cohort of 1,375 infants was recruited from eight hospital postpartum units in Iowa. Parents were asked to provide detailed information on their child's health at 6 weeks, 3, 6, 9 and 12 months of age. Questions were posed concerning occurrence of specific childhood illnesses, including otitis media, at each time point, as well as other factors. RESULTS: Over 70% of children were reported to have experienced one or more episodes of otitis media during their first year of life, with its occurrence much more common during the second six months. Multivariate analyses using Generalized Estimating Equations assessed factors associated with otitis media during the entire 12-month period. These analyses showed that pacifier use, age, male sex, greater number of childcare days, and higher family incomes were significantly associated with occurrence of otitis media. CONCLUSIONS: Multivariate analyses found that the occurrence of otitis media was associated with pacifier use, one of few modifiable risk factors for otitis media.